Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents receive treatment and care in accordance with the comprehensive person-centered care plan and provider orders for 2 of 21 residents in the survey sample, Residents #34 and #56. The findings included: 1. For Resident #34, the facility staff failed to administer Hydroxychloroquine Sulfate (an oral medication prescribed to treat rheumatoid arthritis) as ordered by the provider on six (6) separate occasions. Resident #34's diagnosis list indicated diagnoses, which included, but not limited to Chronic Kidney Disease Stage 5, Rheumatoid Arthritis, Type 2 Diabetes Mellitus, and Essential Hypertension. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 12/06/23 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 indicating the resident was cognitively intact. Resident #34's comprehensive person-centered care plan included a focus area stating the resident was at risk for pain and has RA (rheumatoid arthritis) with an intervention for medications as ordered and monitor for any side effects. Resident #34's current physician's orders included an order for Hydroxychloroquine Sulfate 100 mg by mouth two times a day. According to the resident's February 2024 Medication Administration Record (MAR) and nursing progress notes, Resident #34 did not receive the Hydroxychloroquine Sulfate at the following scheduled administration times: 2/02/24 8:00 AM Licensed Practical Nurse (LPN) #3 documented reason as awaiting arrival from the pharmacy 2/09/24 8:00 AM LPN #1 documented reason as held per nurse practitioner 2/11/24 8:00 AM LPN #1 documented reason as held per nurse practitioner 2/14/24 8:00 AM LPN #1 documented reason as held per nurse practitioner 2/16/24 8:00 AM LPN #5 documented reason as awaiting arrival from the pharmacy 2/19/24 8:00 AM LPN #1 documented reason as held per nurse practitioner On 2/21/24 at 10:39 AM, surveyor spoke with LPN #1 who stated there was a pharmacy issue with the Hydroxychloroquine Sulfate, insurance denied it and the facility had to pay for the medication and it came this past week. On 2/21/24 at 11:04 AM, surveyor spoke with a pharmacy staff member who stated the pharmacy sent a supply of Hydroxychloroquine Sulfate 60 tablets for Resident #34 on 12/15/23, 10 tablets on 2/02/24, and 60 tablets on 2/19/24. On 2/21/24 at 4:34 PM, surveyor spoke with LPN #3 who stated they did not remember if the medication was unavailable at any time and further stated sometimes there are extra medication supplies in the bottom drawer of the medication cart and nurses do not check and just re-order the medications. LPN #3 checked the medication cart in the presence of the surveyor and could only locate one card of Hydroxychloroquine Sulfate with 28 remaining tablets for Resident #34. The label on the card was dated 2/19/24 with a quantity of 60, however, LPN #3 was unable to locate the other card containing 30 tablets of the Hydroxychloroquine Sulfate. On 2/21/24 at 4:38 PM, the survey team met with the Administrator, Director of Nursing (DON), Assistant Director of Nursing and discussed the concerns with Resident #34's prescribed Hydroxychloroquine Sulfate. On 2/22/24 at 9:05 AM, the DON provided a pharmacy delivery receipt indicating the facility also received a delivery of 60 tablets of Hydroxychloroquine Sulfate on 1/10/24 and stated there was an overstock of the medication at one time. On 2/22/24 at 9:11 AM, the DON stated there was an overstock of the Hydroxychloroquine Sulfate for Resident #34 in the facility and the medication was present and available at the times when it was not administered. The DON stated when the medication was not administered it was because the nurses could not find the tablets in the medication cart, but they were there. The DON further stated that the nurse practitioner held the doses when the nurses could not locate the medication until it arrived from the pharmacy. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/22/24. 2. For Resident #56, the facility staff failed to administer Coal Tar Extract Lotion as ordered by the provider. Resident #56's diagnosis list indicated diagnoses, which included, but not limited to Alzheimer's Disease, Generalized Osteoarthritis, and Severe Protein-Calorie Malnutrition. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 1/26/24 coded the resident as being severely impaired in cognitive skills for daily decision making with short-term and long-term memory problems. Resident #56's comprehensive person-centered care plan included a focus area stating (Resident #56) has Psoriasis on back with an intervention stating, Treatment as ordered. According to Resident #56's clinical record, the resident was seen by the nurse practitioner (NP) on 2/14/24. The progress note read in part .(He/she) is seen today per nurse request for evaluation of 'rash'. Dermatitis to back has been present long-term however appears to be spreading, today on examination (he/she) appears to have scaly, patchy appearance similar to psoriasis .start coal tar to back/site daily x 14 days . An order for Coal Tar Extract Lotion 1% apply to back topically one time a day for rash for 14 days was provided on 2/14/24 to start on 2/15/24. According to Resident #56's February 2024 Medication Administration Record (MAR), the Coal Tar was not administered on 2/15/24, 2/19/24, or 2/20/24, on each date, Licensed Practical Nurse (LPN) #1 documented the reason for not administering the medication as held per NP. The Coal Tar was initialed on the MAR by LPN #3 as being administered on 2/16/24 through 2/18/24. On 2/21/24 at 10:40 AM, surveyor spoke with LPN #1 who stated the facility could not get the Coal Tar 1% over the counter, but the pharmacy could get Coal Tar 2% and the order was changed yesterday. LPN #1 stated the medication was not at the facility prior to the order being changed yesterday and was not sure if the medication had been delivered since the reorder. On 2/21/24 at 11:06 AM, surveyor spoke with a pharmacy staff member who stated the Coal Tar 1% was not filled because they were unable to get the medication and now the order had been discontinued. On 2/21/24 at 1:42 PM, surveyor spoke with the Director of Nursing (DON) who stated the pharmacy did not have Coal Tar 1% and Resident #56 had not received any and Coal Tar 2% had been ordered. On 2/21/24 at 2:28 PM, surveyor spoke with LPN #3 who stated they did not actually apply Coal Tar on 2/16/24, 2/17/24 and 2/18/24 but applied A&D ointment and thought it was the same as Coal Tar. On 2/21/24 at 2:38 PM, with the assistance of LPN #3, surveyor observed Resident #56's upper left to mid back, extensive redness with no open areas visualized. On 2/21/24 at 2:44 PM, surveyor spoke with the NP who stated Resident #56's rash was on-going, and the Coal Tar 1% was not available from the pharmacy, and they changed the order to 2% yesterday. The NP stated yesterday was the first-time staff had talked with them about changing the order but also stated they share coverage with another NP. On 2/21/24 at 4:38 PM, the survey team met with the Administrator, DON, and Assistant DON, and discussed the concern of Resident #56 not receiving treatment as ordered to their back since 2/15/24 and LPN #3 signing the MAR for the administration of Coal Tar 1% in error on 2/16/24 through 2/18/24. According to Resident #56's clinical record, the resident received the first administration of Coal Tar to their back on 2/21/24 at 10:15 PM. On 2/22/24 at 9:10 AM, surveyor spoke with the DON who stated they had no additional information regarding Resident #56's Coal Tar. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/22/24.

Based on resident interview, staff interview, clinical record review and facility document review the facility staff failed to assess a resident's ability to safely smoke for 1 of 21 residents, Resident #64. Facility staff failed to complete a smoking assessment for Resident #64 when resident began smoking after admission. The findings included: For Resident #64 the facility staff failed to complete a safe smoking assessment once the resident began smoking. During entrance conference, surveyor was provided with a list of residents that smoke. Resident #64's name was on this list. Resident #64's face sheet listed diagnoses which included but not limited to bipolar disorder, severe, with psychotic features, chronic obstructive pulmonary disease, and generalized anxiety disorder. Resident #64's most recent minimum data set with an assessment reference date of 12/12/23 assigned the resident a brief interview for mental status score of 3 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #64's comprehensive care plan was reviewed and contained a care plan for at risk for injury due to smoking-Date initiated 01/01/2024. Interventions for this care plan included Will be assessed for smoking safety. Resident #64's clinical record was reviewed and contained a Safe Smoking Assessment form dated 11/06/23 which read in part, 1. A. Type of Assessment: Admission. 2. History. 1. Does the Resident Currently Smoke, Use Vape/e-Cig, Use Chewing Tobacco, Use Snuff, or any Other 'Smoking' Device. B. No. 1 A. Resident's Intentions Related to 'Smoking.' A. Intends to remain non-smoking. 5. Summary of Evaluation.1K. Resident non-smoker or intends not to smoke. Resident #64's clinical record contained nurse's notes which read in part, 11/07/2023 Chief Complaint/Nature of Presenting Problem: s/p (status post) hospital stay for pancreatitis. History of Present Illness: . admitted to the facility for skilled services. PMH (past medical history) includes but is not limited to Anxiety disorder, Bipolar 1 disorder, CHF (congestive heart failure), .tobacco use. Social History: reports she has been smoking cigarettes. She has been smoking an average of .5 packs per day ., 11/07/2023 09:00 Note Text: Resident confused and refused medications thus far this shift. Resident refused to let staff obtain vital signs. Risks explained to resident. Resident would not engage in conversation about medications and only asked about smoking. NP (nurse practitioner) made aware., and 11/14/2023 10:51 Note Text: Resident sitting up in wheelchair in dayroom. Requests to go smoke at next smoke break . Surveyor spoke with the family nurse practitioner on 02/21/24 at 3:10 PM. Surveyor asked nurse practitioner if Resident #64 is a smoker, and nurse practitioner stated they are. Surveyor spoke with licensed practical nurse (LPN) #3 on 02/21/24 at 3:40 PM. Surveyor asked LPN #3 if they had completed the initial smoking assessment for Resident #64, and LPN #3 stated they had. Surveyor asked LPN #3 why they had coded the resident as a non-smoker, and LPN #3 stated, She didn't smoke when she first came in, but then decided to. Surveyor asked LPN #3 if a safe smoking assessment should have been completed when the resident decided to smoke, and LPN #3 stated, Honestly, it should have. and Activities usually does those, or therapy. Surveyor asked LPN #3 how long after being admitted did Resident #3 start smoking, and LPN #3 stated, Maybe a week or so before she started back smoking. Surveyor spoke with the activities director on 02/21/24 at 3:50 PM. Surveyor asked activities director if they do the smoking assessments for residents, and activities director stated, I do the contract, not the assessments. Surveyor asked activities director if they look at the smoking assessments prior to having a resident sign the smoking contract, and activities director stated, I'm sure I wouldn't have had her sign a contract without a safe assessment. She's been here over a year now. Activities director provided the surveyor with a copy of the resident's Resident Smoking Contract dated 12/11/23 and signed by the resident and activities director. Surveyor spoke with the administrator on 02/21/24 at 4:10 PM regarding Resident #64. Administrator stated that the facility had resident sign the smoking contract, and they are care planned for smoking. Administrator stated, per facility policy, resident is not due for an updated smoking assessment. Administrator provided surveyor with a copy of a facility policy entitled Resident Smoking Policy which read in part, Procedure: During the admission process, nursing will ask residents if they smoke or have a desire/intent to smoke while in the facility. Anyone answering yes is further assessed for smoking safety awareness and the need for reasonable physical or safety accommodations. The assessment is completed thereafter on readmission, quarterly, and with any significant change in the resident's condition. Surveyor spoke with Resident #64 on 02/22/24 at 9:25 am. Surveyor asked resident how long they have been smoking at the facility, and resident stated they have smoked since admission. Surveyor asked resident if there was ever a time they did not smoke or considered not smoking, and resident stated, No, I'm going to smoke. Surveyor spoke with LPN #5 on 02/22/24 at 12:25 PM regarding Resident #64's care plan for smoking. Surveyor asked LPN #5 if resident should have been care planned for smoking upon admission, and LPN #5 stated, She wasn't smoking when she first came, because they wouldn't let her. When I found out she was smoking, I done a care plan for it. Surveyor spoke with the director of nursing (DON) on 02/02/22/24 at 12:30 PM regarding Resident #64. DON stated that resident was not smoking when they were admitted but started smoking after admission. The concern of not completing a safe smoking assessment for Resident #64 was discussed during a meeting with the administrator, DON, assistant DON, and regional director of clinical services on 02/22/24 at 12:45 PM. Facility staff stated that facility policy indicated that smoking assessments are only required upon admission, quarterly and with significant change. The policy does not address residents who choose to start smoking after being admitted and outside of these assessment times. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to provide respiratory care consistent with the comprehensive person-centered care plan and the provider orders for 1 of 21 residents in the survey sample, Resident #34. The findings included: For Resident #34, the facility staff failed to administer supplemental oxygen as ordered by the physician. Resident #34's diagnosis list indicated diagnoses, which included, but not limited to Chronic Kidney Disease Stage 5, Rheumatoid Arthritis, Type 2 Diabetes Mellitus, and Essential Hypertension. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 12/06/23 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 indicating the resident was cognitively intact. Resident #34 was coded as receiving oxygen therapy. Resident #34's comprehensive person-centered care plan included a focus area stating in part .O 2 (oxygen) therapy as ordered with an intervention stating O2 as ordered. On 2/21/24 at 8:58 AM and 2/21/24 at 3:59 PM, surveyor observed Resident #34 in bed receiving oxygen via nasal cannula at the delivery rate of 4 liters per minute (l/m) per the oxygen concentrator setting. The oxygen concentrator was located on the opposite side of the resident's privacy curtain at each observation. Resident #34's current physician's orders included an order dated 1/02/24 for oxygen at 3 l/m via nasal cannula. Surveyor requested and received the facility policy titled Oxygen Administration (all routes) Policy with a revision date of 12/18/23 which read in part Licensed clinicians with demonstrated competence will administer oxygen via the specified route as ordered by a provider . On 2/21/24 at 4:38 PM, the survey team met with the Administrator, Director of Nursing, and the Assistant Director of Nursing and discussed the concern of Resident #34 receiving oxygen at the rate of 4 l/m instead of the ordered rate of 3 l/m. No further information regarding this concern was presented to the survey team prior to the exit conference on 2/22/24.

Based on observations, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a medication error rate of less than 5%. There were two (2) medication errors in 29 opportunities for a medication error rate of 6.9%. These medication errors affected Resident #12 and/or Resident #57. The findings included: For Resident #12, the facility staff failed to administer Calcium-Vit D-Min Oral Tablet 600-400 mg-unit; this was documented on Resident #12 medication administration record (MAR) to be provided one time a day. On 2/21/24 at 8:18 a.m., Licensed Practical Nurse (LPN) #4 was observed to provide Calcium 500 mg-Vitamin D 5 mcg. On 2/21/24 at 9:58 a.m., LPN #4 confirmed they had provided Resident #12 the Calcium 500 mg tablet. On 2/21/24 at 10:22 a.m., LPN #4 stated they did not have the Calcium 600/Vit D 400 tablet in the medication cart during Resident #12's aforementioned medication administration observation. For Resident #57, the facility staff failed to administer Senna S (sennosides 8.6 mg and docusate 50 mg) as ordered by the medical provider. Resident #57's medication administration record (MAR) indicated Senna S was to be provided, one (1) tablet, twice a day. On 2/21/24 at 8:58 a.m., LPN #3 was observed to provide Resident #57 a medication that only contained sennosides 8.6 mg; the docusate component of the order was not administered. On 2/21/24 at 9:35 a.m., the surveyor shared this observation with the facility's Director of Nursing (DON). The following information was found in a facility pharmacy services policy titled 6.0 General Dose Preparation and Medication Administration (with the most recent revision date of 1/1/22): Prior to administration of medication, Facility [sic] staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: . Facility staff should: - Verify each time a medication is administered that it is the correct medication, at the correct dose . - Confirm the MAR reflects the most recent medication order . The survey team met with the facility's Administrator, DON, and Assistant DON on 2/21/24 at 4:43 p.m. During this meeting, the surveyor discussed the aforementioned medication administration observations which had resulted in a medication error rate of 6.9%.

Based on staff interviews, clinical record review, and facility document review, the facility staff failed to maintain complete and/or accurate clinical record for three (3) of 21 sampled residents (Resident #66, Resident #101, and Resident #154). The findings included: 1. Resident #101's clinical record failed to include documentation of the change in the resident's condition which resulted in an increase in the resident's pain medication dosage. Resident #101's clinical record failed to include documentation of the medical provider notification which had resulted in the medical provider increasing the resident's pain medication dosage. Resident #101's medication orders indicated: - On 11/24/23 at 7:53 p.m., the resident's pain medication Morphine was increased from 0.5 ml every four (4) hours as needed to 1.0 ml scheduled to be provided every four (4) hours. No documentation in Resident #101's clinical record provided information as to the change in the resident's condition which resulted in this change in the medication order. - On 11/25/23 at 10:46 a.m., the resident's pain medication Morphine was increased from 1.0 ml scheduled to be provided every four (4) hours to 1.0 ml scheduled to be provided every (2) two hours. No documentation in Resident #101's clinical record provided information as to the change in the resident's condition which resulted in this change in the medication order. On 2/22/24 at 8:40 AM, the surveyor asked the facility's Director of Nursing (DON) for Resident #101's documentation related to the resident's condition change which resulted in the aforementioned changes in the resident's pain medication orders. On 2/22/24 at 9:29 a.m., the facility's Director of Nursing (DON) provided the surveyor with a note that had been obtained from Resident #101's hospice provider. This note was dated 11/24/23 but did not include a time. This note was documented as being printed on 2/22/24 at 8:53 a.m. This note indicated facility staff members communicated, that the resident was requesting an increase in their pain medication, to the hospice provider staff. This note did not detail the resident's assessment/condition related to the request for, and the subsequent decision to, increase Resident #101's pain medication. On 2/22/24 at 11:54 a.m., the Nurse Practitioner (NP), who increased Resident #101's morphine from 1.0 ml every four (4) hours to 1.0 ml every two (2), stated they could have entered the order from home. The NP reported they did not see Resident #101. The following information was found in a facility document titled Resident Change in Condition Policy (with a last revised date of 2/9/24): - The Resident/Physician or Provider/Family/Responsible Party [sic] will be notified when there has been: . A need to alter the resident's medical treatment, including a change in provider orders . - The nurse will record the information related to the change in condition and subsequent events and notifications in the resident's health record. On 2/22/24 at 9:43 a.m., the surveyor met with the facility's Administrator, DON, and Regional Vice-President of Clinical Services (RVCS). The lack of facility documentation related to Resident #101's condition/assessment which resulted in the need to increase the pain medication was discussed. The lack of documentation of the medical provider communication which resulted in the aforementioned changes in Resident #101's medications was discussed. On 2/22/24 at 12:49 p.m., the survey team met with the facility's Administrator, DON, Assistant DON, and RVCS. The surveyor discussed the absence of documentation related to Resident #101's condition/assessment when pain medications were increased. The surveyor discussed the absence of documentation detailing the facility staff contacting Resident #101's medical providers to obtain the orders to address Resident #101's pain medication needs. 2. The facility staff failed to ensure that Resident #154's Durable Do Not Resuscitate Order (DDNR) form was complete and/or accurate. The DDNR form has a section where the individual completing the form certifies that the resident is either capable or incapable of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment. This section was not answered by the individual completing Resident #154's DDNR Order form. The DDNR form has a section that is to be completed when the resident is determined to be incapable of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment . This section identifies by whom and/or under what authority the DDNR was issued for a resident who had been determined incapable in the aforementioned section. This section was answered for Resident #154 even though the previous section has been left unanswered. This DDNR was not signed by Resident #154; it was signed by a family member. On 2/21/24 at 8:14 a.m., the facility's Administrator provided the survey team with a copy of a document titled Authorized Durable Do Not Resuscitate Order Form & Instructions. This form was not dated. This form did not identify its source. The Administrator reported that this document does not specifically address requiring the aforementioned sections of the form to be marked. On 2/21/24 at 4:43 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), and Assistant DON. During this meeting, Resident #154's DDNR order form not being complete was discussed. 3. The facility staff failed to ensure that Resident #66's Durable Do Not Resuscitate Order (DDNR) form was complete and/or accurate. The DDNR form has a section where the individual completing the form certifies that the resident is either capable or incapable of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment. This section was not answered by the individual completing Resident #66's DDNR Order form. The DDNR form has a section that is to be completed when the resident is determined to be incapable of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment . This section identifies by whom and/or under what authority the DDNR was issued for a resident who had been determined incapable in the aforementioned section. This section was not answered for Resident #66. Resident #66 did not sign the DDNR form; the DDNR form was signed by Resident #66's offspring. On 2/12/24 at 8:14 a.m., the facility's Administrator provided the survey team with a copy of a document titled Authorized Durable Do Not Resuscitate Order Form & Instructions. This form was not dated. This form did not identify its source. The Administrator reported that this document does not specifically address requiring the aforementioned sections of the form to be marked. On 2/21/24 at 4:43 p.m., the survey team met with the facility's Administrator, Director of Nursing (DON), and Assistant DON. During this meeting, Resident #66's DDNR order form not being complete was discussed.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow established infection control guidelines to decrease the potential of and/or risk for infection transmission for 1 of 21 current residents, Resident #96. The findings included: During a surgical wound care observation, the facility staff failed to complete hand hygiene and was observed to touch dressing supplies used to clean the wound with their bare hands. Resident #96's diagnoses included, but were not limited to, fractures, attention deficit hyperactivity disorder, anxiety disorder, and bipolar disorder. Section C (cognitive patterns) of Resident #96's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 02/04/24 included a brief interview for mental status (BIMS) score of 15 out of a possible 15 points. Resident #96's comprehensive care plan included the focus areas, traumatic subluxation of peroneal tendon of left foot. Resident 96's clinical record included a provider order to change dressing to left lower extremity everyday, cleanse with betadine, apply xeroform, cover with ABD pad, and wrap gently with kerlix. 02/20/24 at 3:20 p.m., the surveyor observed Licensed Practical Nurse (LPN) #1 and LPN #2 complete Resident #96's surgical wound treatment. LPN #2 prepared the supplies that included xeroform, ABD pads, kerlix, 4X4 dressings (gauze), dermal wound wash, and betadine. LPN #2 was observed to touch the 4X4's with their bare hands and placed the 4X4's in two clear cups. LPN #2 was observed to add betadine to one cup and dermal wound wash to the other. LPN #2 took the items to the bedside. The surveyor requested LPN #2 to step outside the room and asked LPN #2 if they had touched the 4X4 gauze with their bare hand. LPN #2 verbalized they had, discarded the items, put gloves on and obtained new 4X4 gauze, put part of the 4X4 gauze in one cup and part in a second cup, applied dermal wound cleanser to one cup of the gauze and betadine to the other. LPN #1 was observed by the surveyor to clean the surgical wound on left foot with dermal cleaner, apply betadine, xeroform, ABD pads, and kerlix. LPN #1 was not observed to change their gloves or perform any hand hygiene after cleansing the wound, applying betadine, or before applying any dressing(s). 02/21/24 at 9:20 a.m., LPN #1 was asked if they completed any hand hygiene after touching the wound. LPN #1 stated they had washed their hands prior to beginning the wound care, had dabbed at the surgical wound with the wound cleanser but did not complete any hand hygiene after starting the treatment. 02/21/24 at 8:50 a.m., during an interview with the infection control nurse, this nurse stated the nurse should have completed hand hygiene during wound care. When asked about touching the 4X4's with their bare hands this staff stated it would depend on if the 4X4's came out of a sterile packet. On 02/21/24 at 9:25 a.m., the Director of Nursing (DON) was made aware of the issue with wound care and the policy regarding wound care was requested. On 02/21/24 at 12:50 p.m., the Administrator provided the survey team with a copy of a policy titled, Hand Hygiene/Handwashing Policy. This policy read in part, .Perform hand hygiene .before and after having direct contact with residents, after removing gloves .After contact with body fluids or excretions .non-intact skin and/or wound dressings, If moving from a contaminated body site to a clean body site during resident care . 02/21/24 at 4:38 p.m., during an end of the day meeting with the Administrator, DON, and Assistant Director of Nursing (ADON) the issues with the wound care observation were reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation and staff interview, the facility staff failed to prepare, distribute, and serve food in a manner that would prevent foodborne illnesses. The sanitizing cycle of the dishwashing machine was not working. The findings included: The sanitizing cycle of the dishwashing machine in the facility kitchen was not working. The test strips did not detect any sanitizing solution. On 02/20/24 at approximately 11:00 a.m., during the initial observation of the facility kitchen Dietary Employee #1 attempted to check the sanitizing solution of the dishwashing machine. Dietary Employee #1 used three different test strips to check the sanitizing solution. None of these test strips changed color. The sanitizing solution bucket was observed to be approximately 2/3 full of solution and the surveyor observed the system that pulled the sanitizer solution into the machine turning. Dietary Employee #1 stated they would call maintenance and would wash dishes by hand. 02/20/24 at 12:15 p.m., the Maintenance Director stated they had checked the dishwashing machine, the sanitizer line in the kitchen was leaking air and it had been replaced. 02/20/24 at 4:30 p.m., during a second observation of the kitchen Dietary Employee #1 stated maintenance had replaced the sanitizing solution line. Dietary Employee tested the solution with a test strip with no further problems being identified. On 02/20/24 at approximately 4:45 p.m., during an end of the day meeting with the Administrator and Director of Nursing the issue with the sanitizing solution was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide written bed hold policy information to the resident or resident representative prior to transfer for 1 of 4 closed record reviews, Resident #86. For Resident #86, the facility failed to provide the resident written bed hold policy information prior to transfer to an acute care hospital. The findings included: Resident #86's clinical record included the medical diagnoses, diabetes, dependence on respirator, neuromuscular dysfunction of bladder, chronic respiratory failure with hypoxia, and tachycardia. Section C (cognitive patterns) of Resident #86's significant change minimum data set (MDS) assessment with an assessment reference date (ARD) of 06/24/22 was coded 1/1/3 to indicate the resident had problems with long and short term memory and was severely impaired in cognitive skills for daily decision making. The residents clinical record included an interact form dated 06/29/22 indicating the resident was transferred to a local hospital. On 07/11/22 the Social Worker, documented Resident #86 had been admitted to the hospital. During the record review, the surveyor was unable to find any documentation that referenced a bed hold. 09/29/22 11:25 a.m., the Administrator stated they were unable to find a bed hold for this resident and provided the surveyor with a copy of their policy titled, Bed Hold Letter Policy. This policy read in part, It is the policy of the facility to track Medicaid bed hold days and notify appropriate parties via Medicaid Bed Hold Letter. The Administrator stated they were aware of the issue regarding offering bed holds and were currently completing audits. Resident #86's primary payer was documented as Medicaid VA CCC Plus Vent. No further information regarding this issue was provided to the survey team prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to determine that medication self-administration for 2 out of 34 residents was appropriate (Resident #91 and Resident #95). The findings included: 1. The facility staff failed to assess Resident #91 for medication self-administration of eye drops (Systane Ultra). The clinical record of Resident #91 was reviewed 7/15/19 through 7/18/19. Resident #91 was admitted to the facility 6/13/19 with diagnoses, that included but not limited to sepsis, metastatic colon cancer, type 2 diabetes mellitus, morbid obesity, urogenital implants, chronic urinary retention, hypertension, chronic obstructive pulmonary disease, obstructive sleep apnea, systemic lupus erythematous, depression, and congestive heart failure. Resident #91's admission minimum data set (MDS) with an assessment reference date (ARD) of 6/20/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. The surveyor interviewed Resident #91 on 7/15/19 at 6:31 p.m. During this interview, the surveyor observed a bottle of Systane Ultra eye drops on the over the bed table. The bottle of eye drops did not have a label with directions for use. Resident #91 stated the eye drops were used for dry eyes. The surveyor reviewed the clinical record for an order for Resident #91 to administer the Systane Ultra eye drops independently; reviewed the current comprehensive care plan for medication self-administration; and reviewed the clinical record for an assessment for medication self-administration. The surveyor was unable to locate any of the above items in the clinical record. The surveyor interviewed the director of nursing (DON) on 7/16/19 at 2:06 p.m. about the medication self-administration process. The DON stated an assessment of that resident would be done prior to the start of medication self-administration. The surveyor asked the DON to see if Resident #91 had a medication self-administration assessment for Systane Ultra eye drops. The DON informed the surveyor on 7/16/19 at 2:30 p.m. that a medication self-administration assessment had not been completed on Resident #91. The DON stated someone from the resident's family probably brought the medicine in. The surveyor requested the facility policy on medication self-administration on 7/16/19. The surveyor reviewed the facility policy titled Self Administration of Medication Date Revised May 2016. The policy read in part 1. Verify physician's order in the resident's chart for self-administration of specific medications under consideration. 2. Complete Self-Administration of Medications Assessment form (AL 1008) with the resident. 5. In the event the Interdisciplinary team has determined the resident safe to administer medication (s), administration of medication (s) will be Care Planned for approved self-administered medication. 8. The MAR (medication administration record) must identify medications that are self-administered and the medication nurse will need to follow-up with the resident as to documentation and storage of medication during each medication pass. If medication (s) are kept at bedside, it must be kept in a locked box. The surveyor informed the administrator, the director of nursing, the regional director of clinical services, the administrator-in-training, and the regional vice president of operations of the above concern on 7/17/19 at 11:35 a.m. No further information was provided prior to the exit conference on 7/18/19. 2. The facility staff failed to assess Resident #95 for medication self-administration of nasal spray. The clinical record of Resident #95 was reviewed 7/15/19 through 7/18/19. Resident #95 was admitted to the facility 11/10/15 and readmitted [DATE]. Diagnoses included but were not limited to mycoplasma pneumonia, urinary tract infection, type 2 diabetes mellitus, chronic obstructive pulmonary disease, neuromuscular dysfunction of the bladder, hypokalemia, chronic kidney disease, obesity, hypertension, and anemia. Resident #95's 5-day minimum data set (MDS) assessment with an assessment reference date (ARD) of 6/24/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. The surveyor interviewed Resident #95 on 7/16/19 at 11:40 a.m. and observed a bottle of Deep Sea moisturizing nasal spray on the over-the-bed table. The label read that resident may keep at bedside. Use in both nostrils. Resident #95 stated the oxygen tends to dry her nose and the spray helps with the dryness. The surveyor reviewed the clinical record for an order for medication self-administration, an assessment for medication self-administration, and the care plan for medication self-administration. The surveyor was unable to locate any of the above items in the clinical record. The surveyor informed the director of nursing on 7/16/19 at 12:31 p.m. and requested if the DON could locate the order for the nasal spray and the medication self-administration assessment. The DON informed the surveyor on 7/16/19 at 2:04 p.m. that a medication self-administration assessment had not been completed for the resident for the use of the nasal spray. The surveyor requested the facility policy on medication self-administration. The surveyor reviewed the facility policy titled Self Administration of Medication Date Revised May 2016. The policy read in part 1. Verify physician's order in the resident's chart for self-administration of specific medications under consideration. 2. Complete Self-Administration of Medications Assessment form (AL 1008) with the resident. 5. In the event the Interdisciplinary team has determined the resident safe to administer medication (s), administration of medication (s) will be Care Planned for approved self-administered medication. 8. The MAR (medication administration record) must identify medications that are self-administered and the medication nurse will need to follow-up with the resident as to documentation and storage of medication during each medication pass. If medication (s) are kept at bedside, it must be kept in a locked box. The surveyor informed the administrator, the director of nursing, the regional director of clinical services, the administrator-in-training, and the regional vice president of operations of the above concern on 7/17/19 at 11:35 a.m. No further information was provided prior to the exit conference on 7/18/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide a reasonable accommodation by maintaining the breath activated call cord/light within the resident's reach for 1 of 34 residents (Resident #260). The findings included: Resident #260's breath activated call cord was out of reach for twenty-five minutes. The clinical record of Resident #260 was reviewed 7/15/19 through 7/18/19. Resident #260 was admitted to the facility 6/24/19 and readmitted [DATE] with diagnoses that included but not limited to ventilator associated pneumonia, protein-calorie malnutrition, extradural and subdural abscess, quadriplegia, chronic respiratory failure, pressure ulcer sacral region, stage 2, osteomyelitis of vertebra, lumbosacral region, Hepatitis A, Hepatitis B, Hepatitis C, opioid abuse, hypertension, cocaine abuse, stimulant abuse, tracheostomy status, gastrostomy status, and dependence on ventilator. The admission MDS (minimum data set) assessment had not yet been completed but other clinical documentation indicated the resident was not cognitively impaired but did require total assistance with all aspects of care, was a quadriplegia, and was ventilator dependent. Resident #260's current care plan identified the focus area dated 6/25/19 that read the resident is ventilator dependent r/t (related to) respiratory failure. Interventions: Keep call bell within reach. The surveyor interviewed Resident #260 on 7/15/19 at 5:22 p.m. Resident #260 was in bed, ventilator in use. The surveyor observed the breath activated call cord was approximately 1 ½-2 inches from Resident #260's mouth. The surveyor sat in a chair at bedside and interviewed the resident. Resident #260 spoke in a very soft voice. The surveyor did not understand most of the words spoken by the resident. The surveyor had to have ear to Resident #260's mouth in order to hear the spoken words. During the interview, Resident #260 kept trying to blow into the breath activated call cord but was unable to activate it as indicated by his care plan. The call cord was approximately 1 ½ inches-2 inches from the resident's mouth. During the interview of approximately 25 minutes, the surveyor did not witness any staff attempt to check on Resident #260. Upon completion of the interview at 5:40 p.m., the surveyor informed Resident #260's nurse for the day-registered nurse #1 of the above concern. R.N. #1 followed the surveyor to Resident #260's room, adjusted the breath activated call cord and stated the call cord was within reach when checked earlier in the shift. The surveyor informed the administrator, the director of nursing, the regional director of clinical services, the vice president of regional operations, and the administrator-in-training of the above concern on 7/17/19 at 11:35 a.m. No further information was provided prior to the exit conference on 7/18/19.

Based on observation, staff interview, and facility document review, the facility staff failed to provide privacy for 1 of 4 residents observed during a medication pass and pour observation, Resident # S2. The findings included The facility staff failed to pull the privacy curtain to provide privacy while administering medications through a peg tube for Resident # S2. On 9/12/19 at 8:47 am, the surveyor was conducting a medication pass and pour observation with LPN # 1 (licensed practical nurse). The surveyor observed that LPN # 1 did not pull the privacy curtain and Resident # S2 was visible to her roommate as LPN # 1 administered medications to Resident # S2 via peg tube. On 9/12/19 at 10:03 am, the surveyor interviewed LPN # 1. The surveyor asked LPN # 1 why she did not pull the privacy curtain during medication administration for Resident # S2. LPN # 1 stated, I didn't even think about it. Her husband used to be in the room with her, and he used to like to watch her get her medicine. The person that is in there now is usually in therapy when I give her medication, and I didn't think to pull the curtain. The facility policy on Resident Privacy contained documentation that included but was not limited to, . Procedure 2. A closed door, drawn curtain, or both, shields the resident from passerby, as well as their roommate. On 9/12/19 at 2:30 pm, the administrator, the administrator in training, the director of nursing and the regional director of clinical services were made aware of the findings as stated above. The administrative team was provided the opportunity to ask questions and submit more information to dispute the deficient practice as stated above. No further information regarding this issue was provided to the survey team prior to the exit conference on 9/12/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility document review, staff interview and clinical record review, the facility staff failed to report an allegation of abuse to the appropriate agencies for 1 of 12 residents in the survey sample (Resident #209). The findings included: The facility staff failed to report an allegation of abuse to the appropriate agencies for Resident #209. Resident #209 was originally admitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, coronary artery disease, high blood pressure, pneumonia, diabetes, arthritis and dementia. This resident was first admitted to a facility in which it was a sister facility but was transferred to present facility due to being able to meet the increased needs of this resident in a secure unit due to wandering tendencies and family request. This transfer of this resident occurred on 8/23/19. During the clinical record review by the surveyor on 9/11/and 9/12/19, the following documentation was noted on the Admission/readmission Evaluation, which was completed on 8/23/19: o .During the last 90 days resident had No Falls . o The resident's cognitive status changed in the last 90 days was answered as No . o Moderately impaired limited vision, but can identify objects . o Confined to a chair . o Balance not steady, only able to stabilize with physical assistance . o 3 or more medications taken currently or within the last 7 days . o Memory loss . o Resident #209 was also marked as requiring 1 person assist with ambulation, bed mobility, bathing, dressing, eating, toileting, and transfers. The surveyor reviewed the resident's clinical record on 9/11/19 and 9/12/19. During this review, the surveyor noted the following documentation dated and timed for 8/27/19 at 10:57 am which read, While attempting to get resident dressed and cleaned up for the day, resident started yelling before anyone even touched this resident. No, your not going to beat me up and put more bruises on me! Do not touch me, you guys are mean to me! The resident was left alone for now to rest. The surveyor reviewed the nursing notes after this incident and there was no further documentation on the allegation of abuse. On 9/11/19 at approximately 4:45 pm, the surveyor asked the administrative team in the end of the day conference if they had any FRI's (Facility Reported Incidents) on Resident #209 for this date. The director of nursing and the regional nurse consultant both stated they were not aware of any FRI's that had been completed concerning this resident. Both stated they would look into this and provide the surveyor with any information that they find. On 9/12/19 at 9:15 am, the regional nurse consultant, director of nursing (DON) and administrator in training (AIT) were present with the surveyor in the conference room. The regional nurse consultant stated, I was wondering why you asked us for a FRI on this resident yesterday because all that we were aware of was 2 falls that occurred on 8/26 and 8/27/19. Both the DON and I worked late and read the nurses' notes and that was when we found the allegation of abuse that was documented by the nurse of 8/27/19 at 10:57 am. Both the regional nurse consultant and the DON stated they were not aware of this allegation until they were reviewing the notes last night (9/11/19). The regional nurse consultant stated, After finding this out, we immediately faxed in a FRI to your office and notified the appropriate agencies of this allegation. The administrator in training stated that after these measures were taken, the staff was educated on reporting of any allegations of abuse immediately to their supervisor and then follow the chain of command so any allegations that are reported and investigations could be started within 2 hours of being told of an allegation. We have been doing this as staff was clocking into work last night and following through until all staff are in-serviced on this. The surveyor asked if the nurse that wrote this note was working today. The DON stated, No, she is on vacation and not on the schedule. The surveyor asked for a copy of the facility's policy on reporting allegations of abuse or neglect. The surveyor also requested a copy of any in services that staff had received in the past year on abuse and neglect of any resident in the facility. The surveyor was provided with a copy of the facility's policy titled Virginia Resident Abuse Policy which read in part, .Facility staff must immediately report all such allegations to the Administrator/Abuse Coordinator. The Administrator/Abuse Coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy . The administrator in training provided the surveyor with a list of courses that the facility staff are required to have on an annual base. Included in these courses, were the courses on abuse and neglect, who and how to report this to if they ever receive a report of any of this. The surveyor reviewed the documentation on this list and noted there was a completion percentage of 99.12% of staff had completed these annual courses. The unit manager for the Memory Care Unit was interviewed on 9/12/19 at approximately 1 pm in the conference room. The surveyor asked if she had received any allegations of abuse in which Resident #209 had reported to a nurse and then that nurse documented the statements in a nurses' note on 8/27/19 at 10:57 am. The unit manager stated, No one reported this incident to me and I was not aware of it until the DON had shown me the nurses' notes this morning. The surveyor notified the Administrator along with the rest of the administrative team of the above documented findings on 9/12/19 at 3:30 pm. The surveyor asked the administrator if he had been aware of the allegation of abuse that had been documented in the nurses' notes of Resident #209 on 8/27/19 at 10:57 am. The administrator replied, No one knew of this allegation until my staff was reading over the notes last night and found it. No further information was provided to the surveyor prior to the exit conference on 9/12/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, the facility staff failed to immediately start an investigation when 1 of 12 residents in the survey sample alleged abuse by a staff member and failed to report these completed findings within 5 days of the becoming aware of an alleged abuse to a resident in the nursing facility (Resident #209). The findings included: The facility staff failed to immediately investigate an allegation of abuse that was reported to staff by Resident #209 on 8/27/19 at 10:57 am Resident #209 was originally admitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, coronary artery disease, high blood pressure, pneumonia, diabetes, arthritis and dementia. This resident was first admitted to a facility in which it was a sister facility but was transferred to present facility due to being able to meet the increased needs of this resident in a secure unit due to wandering tendencies and family request. This transfer of this resident occurred on 8/23/19. During the clinical record review by the surveyor on 9/11/and 9/12/19, the following documentation was noted on the Admission/readmission Evaluation, which was completed on 8/23/19: o .During the last 90 days resident had No Falls . o The resident's cognitive status changed in the last 90 days was answered as No . o Moderately impaired limited vision, but can identify objects . o Confined to a chair . o Balance not steady, only able to stabilize with physical assistance . o 3 or more medications taken currently or within the last 7 days . o Memory loss . o Resident #209 was also marked as requiring 1 person assist with ambulation, bed mobility, bathing, dressing, eating, toileting, and transfers. The surveyor reviewed the resident's clinical record on 9/11/19 and 9/12/19. During this review, the surveyor noted the following documentation dated and timed for 8/27/19 at 10:57 am which read, While attempting to get resident dressed and cleaned up for the day, resident started yelling before anyone even touched this resident. No, your not going to beat me up and put more bruises on me! Do not touch me, you guys are mean to me! The resident was left alone for now to rest. The surveyor reviewed the nursing notes after this incident and there was no further documentation on the allegation of abuse. On 9/11/19 at approximately 4:45 pm, the surveyor asked the administrative team in the end of the day conference if they had any FRI's (Facility Reported Incidents) on Resident #209 for this date. The director of nursing and the regional nurse consultant both stated they were not aware of any FRI's that had been completed concerning this resident. Both stated they would look into this and provide the surveyor with any information that they find. On 9/12/19 at 9:15 am, the regional nurse consultant, director of nursing (DON) and administrator in training (AIT) were present with the surveyor in the conference room. The regional nurse consultant stated, I was wondering why you asked us for a FRI on this resident yesterday because all that we were aware of was 2 falls that occurred on 8/26 and 8/27/19. Both the DON and I worked late and read the nurses' notes and that was when we found the allegation of abuse that was documented by the nurse of 8/27/19 at 10:57 am. Both the regional nurse consultant and the DON stated they were not aware of this allegation until they were reviewing the notes last night (9/11/19). The regional nurse consultant stated, After finding this out, we immediately faxed in a FRI to your office and notified the appropriate agencies of this allegation. The administrator in training stated that after these measures were taken, the staff was educated on reporting of any allegations of abuse immediately to their supervisor and then follow the chain of command so any allegations that are reported and investigations could be started within 2 hours of being told of an allegation. We have been doing this as staff was clocking into work last night and following through until all staff are in-serviced on this. The surveyor asked if the nurse that wrote this note was working today. The DON stated, No, she is on vacation and not on the schedule. The surveyor asked for a copy of the facility's policy on reporting allegations of abuse or neglect. The surveyor also requested a copy of any in services that staff had received in the past year on abuse and neglect of any resident in the facility. The surveyor was provided with a copy of the facility's policy titled Virginia Resident Abuse Policy which read in part, .Facility staff must immediately report all such allegations to the Administrator/Abuse Coordinator. The Administrator/Abuse Coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy . The administrator in training provided the surveyor with a list of courses that the facility staff are required to have on an annual base. Included in these courses, were the courses on abuse and neglect, who and how to report this to if they ever receive a report of any of this. The surveyor reviewed the documentation on this list and noted there was a completion percentage of 99.12% of staff had completed these annual courses. The unit manager for the Memory Care Unit was interviewed on 9/12/19 at approximately 1 pm in the conference room. The surveyor asked if she had received any allegations of abuse in which Resident #209 had reported to a nurse and then that nurse documented the statements in a nurses' note on 8/27/19 at 10:57 am. The unit manager stated, No one reported this incident to me and I was not aware of it until the DON had shown me the nurses' notes this morning. The surveyor notified the Administrator along with the rest of the administrative team of the above documented findings on 9/12/19 at 3:30 pm. The surveyor asked the administrator if he had been aware of the allegation of abuse that had been documented in the nurses' notes of Resident #209 on 8/27/19 at 10:57 am. The administrator replied, No one knew of this allegation until my staff was reading over the notes last night and found it. No further information was provided to the surveyor prior to the exit conference on 9/12/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review, the facility staff failed to accurately assess 1 of 34 Residents in the survey sample, Resident # 409. The findings included: The facility staff documented assessments in the clinical record, and created a care plan that reflected that Resident # 409 had a urostomy when Resident # 409 did not have a urostomy. Resident #409 was an [AGE] year-old-female that was admitted to the facility on [DATE]. Diagnoses included but were not limited to, urinary tract infection, hypertension, restlessness, and agitation. The clinical record for Resident # 409 was reviewed on 7/16/19 at 10:53 am. At the time of the survey, there were no completed MDS (minimum data set) assessments for Resident # 409. The baseline plan of care for Resident # 409 was initiated on 4/12/19. The facility staff documented a focus area for Resident # 409 as, Resident requires urostomy. Interventions included but were not limited to, Inspect stoma and peristomal skin area with each pouch change. Note: irritation, redness, rashes. Resident # 409 had current orders that included but were not limited to, Suprapubic catheter care q (every) shift and prn (as needed), which was initiated by the physician on 7/12/19. The surveyor reviewed the current physician's orders for Resident # 409 and did not observe any orders for urostomy care for Resident # 409. On 7/16/19 at 3:38 pm, the surveyor observed Resident # 409 as CNA # 1 was providing ADL (activities of daily living) care. The surveyor observed that Resident # 409 had a suprapubic catheter size 20 Fr (French) with a 10 ml (milliliter) balloon. The suprapubic catheter and a leg drainage bag was secured to Resident # 409's left leg. The surveyor did not observe a urostomy site anywhere on Resident # 409's body. On 7/17/19 at 8:04 am, the surveyor reviewed the facility Admission/readmission Evaluation form for Resident # 409 that had been documented on 7/11/19 at 22:00 (10:00 pm). The admission/readmission evaluation form for Resident # 409 contained documentation that included but was not limited to, .13. Urinary Elimination G. Urostomy (check mark observed in box beside urosotmy). A facility 72 Hour Post admission Nursing Note that was documented on 7/12/19 at 10:47 am, contained documentation that included but was not limited to: .5. Skin 4. Comments (Typed in box below comments) Urostomy. A facility CHF (congestive heart failure) Pathway Daily Nursing Note that was documented on 7/13/19 at 9:20 am, contained documentation that included but was not limited to, .2. Evaluation 1. Reason for Resident being skilled? PT, OT (physical therapy, occupational therapy) to treat ADLs, mobility and strengthening. Nursing to monitor vital signs, labs, nutrition, safety, s/p (status post) hospitalization for UTI (urinary tract infection) - Urostomy care. A CHF Pathway Daily Nursing Note that was documented on 7/14/19 at 9:20 am, contained documentation that included but was not limited to, .Skilled Service Progression: Resident skilled for: PT, OT to treat ADLs, mobility and strengthening. Nursing to monitor vital signs, labs, nutrition, safety, s/p hospitalization for UTI - Urostomy care. A CHF Pathway Daily Nursing Note that was documented on 7/15/19 at 9:20 am, contained documentation that included but was not limited to, .Overview: Resident skilled for: PT, OT to treat ADLs, mobility and strengthening. Nursing to monitor vital signs, labs, nutrition, safety, s/p hospitalization for UTI - Urostomy care. Therapies ordered PT OT . A CHF Pathway Daily Nursing Note that was documented on 7/16/19 at 9:20 am, contained documentation that included but was not limited to, .Overview: Resident skilled for: PT, OT to treat ADLs, mobility and strengthening. Nursing to monitor vital signs, labs, nutrition, safety, s/p hospitalization for UTI - Urostomy care. Therapies ordered PT OT . On 7/17/19 at 8:11 am, the surveyor interviewed LPN # 1 (licensed practical nurse). The surveyor asked LPN # 1 if Resident # 409 had a urostomy. LPN # 1 stated, I don't think so but I will go check. On 7/17/19 at 8:15 am, LPN # 1 stated to the surveyor, She does not have a urostomy. She has a suprapubic catheter. On 7/17/19 at 8:21 am, the surveyor interviewed MDS coordinator # 1. The surveyor askes MDS coordinator # 1 to review Resident # 409 baseline care plan. The surveyor and MDS coordinator # 1 observed that Resident # 409 had a focus area for having a urostomy on her baseline care plan. The surveyor asked who generated the focus area for a urostomy for Resident # 409. MDS coordinator # 1 stated, The nurse generated that on admission. On 7/17/19 at 6:42 pm, the regional vice president of operations, the regional director of clinical services, the administrator, the administrator in training, and the director of nursing was made aware of the findings as stated above. The regional director of clinical services agreed that the facility staff had documented that Resident # 409 had a urostomy when in fact Resident # 409 did not have a urostomy. No further information regarding this issue was presented to the survey team prior to the exit conference on 7/18/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility document review, the facility staff failed to provide activities to meet the needs of Residents on 1 of 3 units in the facility and for 3 of 34 Residents in the facility, Resident # 91, Resident # 260, and Resident # 108. The findings included: 1. The facility staff failed to provide group activities for Residents on the [NAME] Fold unit. On 7/15/19 at 4:32 pm, the surveyor was making observations on the [NAME] fold unit. The surveyor observed an activity calendar for July 2019 that was posted on the unit. The surveyor observed that the activity calendar had Coffee Club as an activity that was to be conducted at 4:30 pm. The surveyor did not observe any staff member conducting a group activity with the Residents on the unit. On 7/15/19 at 4:47 pm, the surveyor continued to conduct observations on the [NAME] Fold unit and did not observe any staff member conducting a group activity with the Residents on the unit. On 7/15/19 at 5:02 pm, the surveyor continued to conduct observations on the [NAME] Fold unit and did not observe any staff member conducting a group activity with the Residents on the unit. On 7/16/19 at 9:35 am, the surveyor observed that the activity calendar posted on the [NAME] Fold unit had Exercise posted to be conducted at 9:30 am. The surveyor did not observe any staff member conducting group activities with the Residents on the unit at that time. On 7/16/19 at 9:47 am, the surveyor continued to conduct observation on the [NAME] Fold unit and did not observe any staff member conducting group activities with the Residents on the unit. On 7/16/19 at 10:08 am, the surveyor observed that Noodle Ball was posted to be conducted at 10:00 am on the activity calendar that was posted on the unit. The surveyor did not observe any staff member conducting group activities with the Residents on the unit. On 7/16/19 at 10:35 am, the surveyor reviewed the activity calendar that was posted on the unit. The activity calendar had Hand & Nails as an activity that was to be conducted at 10:30 am. The surveyor did not observe any staff member conducting group activities with the Residents on the unit. On 7/16/19 at 11:10 am, the surveyor reviewed the activity calendar that was posted on the unit. The calendar had Rummy as an activity that was to be conducted at 11:00 am. The surveyor did not observe any staff member conduct group activities with the Residents on the unit. On 7/16/19 at 2:08 pm, the surveyor reviewed the activity calendar that was posted on the unit. The calendar has About the Past as an activity that was to be conducted at 2:00 pm. The surveyor did not observe any staff member conduct group activities with the Residents on the unit. On 7/17/19 at 8:30 am, the surveyor met with the administrator in training and the director of nursing and reported the observations as stated above. The administrator in training informed the surveyor that the facility activity director was in Richmond testing during the week of the survey. The surveyor asked the administrator in training who assisted with activities when the activity director was not present in the facility. The administrator in training informed the surveyor that the CNAs (certified nursing assistants) and the activity assistant helped with activities when the activity director was absent. The surveyor informed the administrator in training that there were no observations of CNAs conducting group activities with the Residents on the unit, and the surveyor did not observe the activity assistant on the [NAME] Fold unit conducting group activities. The administrator in training stated, She was busy with the rest of the building. On 7/17/19 at 8:40 am, the surveyor interviewed the facility activity assistant. The surveyor made the activity assistant aware that she did not observe group activities being conducted with the Residents on [NAME] Fold on 7/15/19 and 7/16/19. The activity assistant informed the surveyor that she had been busy working on the other units and did not get to [NAME] Fold to conduct activities. The facility Activity Program/Calendar Policy contained documentation that included but was not limited to, .Policy: The facility will provide activity programming to promote physical, cognitive, and/or emotional health, and that supports self-expression, exercise, socialization, lifestyle programs and leisure pursuits. Procedure: C) Activities will be offered every day for a minimum of six hours per day and including at least 2 evenings per week at hours offered at times convenient for the residents, and not to interfere during specific nursing care (i. e. medication administration) times. On 7/17/19 at 6:42 pm, the regional vice president of operations, the regional director of clinical services, the administrator, the administrator in training, and the director of nursing was made aware of the findings as stated above. No further information regarding this issue was presented to the survey team prior to the exit conference on 7/18/19. 2. The facility staff failed to provide an on-going program of activities designed to meet the needs, in accordance with the comprehensive assessment, the interests, and the physical, mental, and psychosocial well-being of Resident #260. The clinical record of Resident #260 was reviewed 7/15/19 through 7/18/19. Resident #260 was admitted to the facility 6/24/19 and readmitted [DATE] with diagnoses that included but not limited to ventilator associated pneumonia, protein-calorie malnutrition, extradural and subdural abscess, quadriplegia, chronic respiratory failure, pressure ulcer sacral region, stage 2, osteomyelitis of vertebra, lumbosacral region, Hepatitis A, Hepatitis B, Hepatitis C, opioid abuse, hypertension, cocaine abuse, stimulant abuse, tracheostomy status, gastrostomy status, and dependence on ventilator. The admission MDS (minimum data set) assessment had not yet been completed but other clinical documentation indicated the resident was not cognitively impaired, did require total assistance with all aspects of care, was a quadriplegia, and was ventilator dependent. Resident #260's current care plan dated 7/8/19 read that the resident had made personal preferences known. She enjoys watching television, playing bingo, listening to music, socializing. Interventions: Have family involved with POC (plan of care), have snacks between meals, help keep personal belongings taken care of in the room and facility. The surveyor interviewed Resident #260 on 7/15/19 at 5:22 p.m. Resident #260 was in bed, ventilator in use. The surveyor asked the resident about activities. Resident #260 stated in a very soft voice that she was ready to go to activities. The surveyor reviewed Resident #260's Activities Evaluation Initial completed 7/8/19. Interests marked were bingo, small group, cards, one to one, movies, music, reading, current events, social/parties, family/friend visits, and television. The surveyor interviewed the activity assistant on 7/17/19 at 9:37 a.m. The activity assistant stated Resident #260 attended social activities-sits in lounge area and talks with others. The activity assistant stated the resident had no active participation in an activity. The activity assistant stated the activity director (AD) was out of the facility this week and the activity director (AD) typically does 1-1 visits. The activity assistant was unable to locate documentation of any 1-1 visits. The surveyor reviewed Resident #260's Individual Resident Daily Participation Record on 7/17/19. Group discussion was marked with an A from 7/2/19-7/16/19. A=active participation. Social/Parties was also marked with an A from 7/2/19 through 7/16/19. During the survey from 7/15/19 through 7/18/19, the surveyor did not see Resident #260 participate in activities. The majority of the day Resident #260 sat in a small lounge across from the special care unit nurse's station. The surveyor did observe a male resident sitting with her during some of this time. The surveyor requested a copy of the July 2019 calendar from the activity assistant on 7/17/19. Many of Resident #260's interests were scheduled on the calendar yet Resident #260 did not attend per the individual participation record: Bingo scheduled on 7/4/19, 7/6/19, 7/8/19, 7/11/19, 7/13/19, and 7/15/19. Resident #260 did not attend any of these based on the individual record of participation. Music time scheduled on 7/7/19, 7/8/19, 7/14/19 and 7/15/19- Resident #260 did not attend any of these based on the individual record of participation. Cards scheduled on 7/9/19 and 7/16/19. Resident #260 did not attend any of these based on the individual record of participation. The surveyor informed the DON on 7/18/19 at 8:25 a.m. of the concern with activities. The DON stated she couldn't speak about activities but would try to get in touch with the AD for activities. The surveyor informed the administrator, the director of nursing, the regional director of clinical services, the vice president of regional operations, and the administrator-in-training of the above concern on 7/17/19 at 11:35 a.m. No further information was provided prior to the exit conference on 7/18/19. 3. The facility staff failed to provide an on-going program of activities designed to meet the needs, in accordance with the comprehensive assessment, the interests, and the physical, mental, and psychosocial well-being of Resident #91. The clinical record of Resident #91 was reviewed 7/15/19 through 7/18/19. Resident #91 was admitted to the facility 6/13/19 with diagnoses, that included but not limited to sepsis, metastatic colon cancer, type 2 diabetes mellitus, morbid obesity, urogenital implants, chronic urinary retention, hypertension, chronic obstructive pulmonary disease, obstructive sleep apnea, systemic lupus erythematous, depression, and congestive heart failure. Resident #91's admission minimum data set (MDS) with an assessment reference date (ARD) of 6/20/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #91's current comprehensive care plan dated 6/25/19 and revised 7/8/19 read, Alteration in supervised/organized recreation characterized by little or no involvement, lack of attendance related to isolation. The resident likes to watch tv and read. Interventions: Arrange 1-1 contracts, determine feasibility of offering activities of interest to resident that are not currently offered, offer activity program directed towards specific interests/needs of resident. The surveyor interviewed Resident #91 on 7/15/19 at 6:25 p.m. The resident was asked about activities. Resident #91 stated, The activity lady came in and talked to me but I've never seen the activity lady again. Resident #91 stated he/she had not attended any activities. Resident #91 stated that he/she watches tv (television) and reads the Bible while in the room. The surveyor reviewed Resident #91's Activities Evaluation Initial completed 6/17/19. Activity pursuit patterns and preferences indicated the resident liked bingo, small groups, reading, television, and family/friend visits. The surveyor interviewed the activity assistant on 7/17/19 at 9:40 a.m. and asked what activities Resident #91 attended. The activity assistant reviewed the Individual Resident Daily Participation Record and stated the only thing documented was tv (television) and current news/events. The surveyor stated both of those activities the resident can do without leaving the room. The activity assistant agreed. The activity assistant stated the activity director (AD) was out of the facility this week and the activity director (AD) typically does 1-1 visits. The activity assistant was unable to locate documentation of any 1-1 visits. The surveyor requested a copy of the July 2019 activity calendar. The July 2019 Individual Resident Daily Participation Record was reviewed. Television was marked with an A from 7/1/19 through 7/16/19 for television and current events/news. A= active participation. During the survey from 7/15/19 through 7/18/19, the surveyor observed Resident #91 in bed with the television on and with the Bible in it's case on the over-the-bed table Resident #91 was currently on reverse isolation. The surveyor requested a copy of the July 2019 calendar from the activity assistant on 7/17/19. Many of Resident #91's interests were scheduled on the calendar yet Resident #91 did not attend per the individual participation record: Bingo scheduled on 7/4/19, 7/6/19, 7/8/19, 7/11/19, 7/13/19, and 7/15/19. Resident #91 did not attend any of these based on the individual record of participation. The surveyor informed the DON on 7/18/19 at 8:25 a.m. of the concern with activities. The DON stated he/she couldn't speak about activities but would try to get in touch with the AD for activities. The surveyor informed the administrator, the director of nursing, the regional director of clinical services, the vice president of regional operations, and the administrator-in-training of the above concern on 7/17/19 at 11:35 a.m. No further information was provided prior to the exit conference on 7/18/19. 4. The facility staff failed to provide recreational activities for Resident #108. Resident #108 was admitted to the facility on [DATE]. Resident #108's diagnoses included, but were not limited to: heart failure, peripheral vascular disease, diabetes mellitus, arthritis, and non-Alzheimer's dementia. Resident #108's 7/1/19 minimum data set (MDS) assessment indicated the resident was able to express ideas and wants; the resident was oriented to year and month; and the Activity Preferences section documented it being 'very important' for the resident to listen to music, be around pets, and keep up with the news. Observations of Resident #108 on 7/15/19, 7/16/19, and 7/17/19 failed to find the resident participating in recreational activities. Clinical documentation also failed to provide evidence Resident #108 had participated in recreational activities during her stay at the facility. Resident #108's care plan included the following Focus information: Alteration in supervised/organized recreation characterized by little or no involvement, lack of attendance related to: cognitive impairment, impaired mobility, impaired social interaction. The following interventions were listed related to this 'Focus' area: -Arrange 1:1 contacts with resident -assist with transport resident to activities [sic] -Engage resident in group activities -Familiarize resident with nursing home environment and activities programs on regular basis [sic] -Invite and encourage family to attend -Praise all efforts. The aforementioned care plan was provided to the surveyor by the facility's Administrator-In-Training (AIT) on 7/18/19 at 11:10 a.m.; the AIT reported no evidence was found to indicate this care plan had been implemented. The AIT reported to the surveyor that an activities staff member had unsuccessfully been attempting to contact Resident #108's family to identify activities the resident would enjoy. The failure of facility staff to have evidence of recreational activities being provided to Resident #108 was discussed during a survey team meeting with the facility's administrative staff on 7/18/19 at 11:55 a.m. The facility's Director of Nursing, Administrator, Administrator-In-Training, and Regional Director of Clinical Services were present at this meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and clinical record review, the facility staff failed to provided services outline in the comprehensive care plan by following the physician's order in regards to notifying the physician when the resident's weight exceded 3 pounds for 1 of 34 residents, Resident #19. The findings included: The facility staff failed to notify the physician when Resident #19's weight gain exceeded 3 (three) pounds following dialysis. The order read to obtain weight upon return from dialysis and notify the physician of a weight gain greater than 3 (three) pounds (lbs). Resident #19's clinical record was reviewed on 07/16/19 through 07/18/19. The review reveal Resident #19 was initially admitted to the facility on [DATE] and was most recently re-admitted on [DATE]. Diagnoses included but were not limited to, congestive heart failure, type 2 diabetes, and chronic kidney disease, stage 4 (severe). Section C (cognitive patterns) of the Residents' quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 04/22/19 and included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points. The Resident's electronic clinical record under the tab labeled orders contained an order with a start date of 06/08/19 at 7:00 p.m. that read to obtain weight upon return from dialysis. Notify MD if 3+ lbs is noted, every night shift Tue, Thu, Sat. The Resident's care plan contained, but not limited to, a focus area of CHF (congestive heart failure) which listed interventions to include monitoring weight. Another focus area read, Resident is on hemodialysis. 3 days week. Tues., Thur., Saturday. (listed name and address of dialysis facility) with one of the interventions to restrict fluids. Resident #19's MAR (medication administration record) noted a weight gain greater than 3 (three) pounds on both Tuesday, 06/11/19 and Saturday, 06/15/19: • Weight: 243.2 lbs (pounds) on Saturday, 06/08/19 and 248.2 lbs on Tuesday, 06/11/19 reflecting a gain of 5 lbs. • Weight: 249.2 lbs on Thursday, 06/13/19 and 253.4 lbs on Saturday, 06/15/19 reflecting a gain of 4.2 lbs. The facility's director of nursing (DON) and nurse practitioner (NP) were interviewed in the conference room on 07/17/19 at 4:10 p.m. The NP acknowledged the order read to notify the provider of a weight gain over 3 (three) pounds and stated she would expect to be notified of that weight gain especially if the weight gain was accompanied by other signs or symptoms of congestive heart failure (CHF) such as shortness of breath (SOB). The DON explained that since Resident #19 usually returned from dialysis later in the evening, sometimes as late as 7:00 p.m. or after, the staff weighed the Resident on night shift (night shift started at 7:00 p.m.) The NP stated her expectation would be the staff would write a note for the NP to see the next morning unless the Resident's condition (i.e. SOB) required sooner notification. The DON planned to look for any evidence the staff had notified the provider of the 2 (two) weights in June that were over 3 lbs. The DON was interviewed in the conference room on 07/18/19 at 9:25 a.m. She reiterated that if Resident #19 did not display any signs or symptoms of distress such as SOB, the facility staff would write the Resident's weight gain in the NP's rounding book for the NP to review the next day. The facility's process was that once the NP had reviewed the rounding book, the notes were shredded and therefore there was no evidence the staff had reported Resident #19's weight gains of over 3 lbs. The administrator, administrator in training, director of nursing, regional director of clinical services, and regional vice president of operations were notified of the above referenced concern on 07/17/19 at 11:35 a.m. The administrator, administrator in training, director of nursing, and regional director of clinical services were notified again on 07/18/19 at 11:56 a.m. No further information regarding this issue was provided to the survey team prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to ensure that the resident received services and assistance to maintain continence by assuring that there was a physician order for the size of the indwelling Foley catheter and balloon for 1 of 34 residents (Resident #79). The findings included: The clinical record of Resident #79 was reviewed 7/15/19 through 7/18/19. Resident #79 was admitted to the facility 5/2/19 and readmitted [DATE] with diagnoses that included but not limited to pneumonia, persistent vegetative state, adult failure to thrive, severe sepsis with septic shock, neuromuscular dysfunction of the bladder, dysphagia, hypothyroidism, acute respiratory failure, dependence on respirator, tracheostomy status, unspecified coma, and non-traumatic intracerebral hemorrhage. Resident #79's 30-day minimum data set (MDS) assessment with an assessment reference date (ARD) of 7/3/19 assessed the resident to be in a persistent vegetative state in Section B0100. Section H Bladder and Bowel was coded for the presence of an indwelling catheter under appliance (H0100A) and urinary continence (H0300) was coded as a 9-not rated, resident had a catheter (indwelling, condom), urinary ostomy, or no urine output for the entire 7 days. Resident #79's current comprehensive care plan had the focus area that read Indwelling catheter characterized by inability to control urination. At risk for infection/complications. Attempted d/c (discontinue) of catheter 5/6/19. Unable to void. Dx (diagnosis) neurogenic bladder. Date initiated 5/3/19. Revision on 5/15/19. Interventions: Indwelling cath per orders. The surveyor observed the resident on 7/15/19 at 3:01 PM. A Foley drainage bag was observed from the doorway. A sign on the door indicated the resident was on contact precautions. Certified nursing assistant #1 was providing care during the observation. The surveyor asked C.N.A. #1 for the size of the indwelling Foley catheter. C.N.A. #1 stated the Foley size was 16 FR (French) with a 10 cc (cubic centimeter) balloon. The surveyor reviewed the July 2019 physician's orders for the size of the indwelling Foley catheter and balloon on 7/18/19. The surveyor was unable to locate an order for the size of the catheter and balloon. The surveyor informed the director of nursing on 7/18/19 at 8:51 a.m. and requested the facility policy on the care of indwelling Foley catheters. The DON provided the facility policy on the care of Foleys on 7/18/19 at 10:34 a.m. and stated the July 2019 physician's orders were reviewed and he/she was unable to locate an order for the size of the catheter and balloon. The DON stated the size of the Foley catheter and the balloon size should be included in the order. The surveyor reviewed the facility policy on 7/18/19 titled Indwelling Catheter Use. The policy read Indwelling catheters are used when ordered by a physician to treat a specific medical condition. The surveyor informed the administrator, the director of nursing, the regional director of clinical services and the administrator-in-training of the above issue on 7/18/19 at 11:56 a.m. No further information was provided prior to the e exit conference on 7/18/19.

Based on observation, staff interview, and facility document review, the facility staff failed to provide appropriate care and services in regards to gastrostomy tube for 1 of 4 residents observed during a medication pass and pour observation, Resident # S2. The findings included The facility staff failed to appropriately check gastrostomy tube placement and residual for Resident # S2. On 9/12/19 at 8:47 am, the surveyor conducted a medication pass and pour observation with LPN # 1 (licensed practical nurse). The surveyor observed LPN # 1 as she applied a syringe to Resident # S2's gastrostomy tube and pulled the syringe plunger back. The surveyor observed a small amount of dark yellow liquid residual return into the syringe. The surveyor observed LPN # 1 as she pushed down on the plunger and returned residual the contents to Resident # S2. The surveyor observed LPN # 2 as she removed the plunger from Resident # S2's peg tube, pulled back on the plunger, and replaced the plunger into Resident # S2's gastrostomy tube. The surveyor then observed LPN # 1 place her stethoscope on Resident # S2's stomach and inserted air into Resident # S2's gastrostomy tube to check placement. On 9/12/19 at 10:03 am, the surveyor interviewed LPN # 1. The surveyor asked LPN # 1 why she checked the residual prior to checking placement when preparing to administer medications via gastrostomy tube to Resident # S2. LPN # 1 stated, That's the way I was taught to do it a long time ago. The facility policy relating to Medication Administered through an Enteral Tube contained documentation that included but was not limited to, .Procedure Facility should check the placement of the naso-gastric or gastrostomy tube in accordance with facility policy. Checking gastric residual volume. On 9/12/19 at 4:35pm, the administrator, administrator in training, the director of nursing, and regional director of clinical services were made aware of the findings as stated above. The administrative team was provided the opportunity to ask questions and provide additional information. No further information regarding this issue was presented to the survey team prior to the exit conference on 9/12/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide pain management services through non-pharmacological interventions for pain management prior to the use of pain medication for 3 of 34 residents (Resident #67, Resident #81, and Resident #260). The findings included: nter 1. The facility staff failed to provide non-pharmacological pain interventions prior to the use of pain medication for Resident #67. The clinical record of Resident #67 was reviewed 7/15/19 through 7/18/19. Resident #67 was admitted to the facility 5/10/19 and readmitted [DATE], 6/17/19 and 7/3/19 with diagnoses that included but not limited to dependence on respirator, type 2 diabetes mellitus, chronic atrial fibrillation, hypertension, cardiac pacemaker, anemia, cirrhosis of the liver, gastrostomy tube, acute viral hepatitis, sedative, hypnotic, or anxiolytic dependence, opioid dependence, pyothorax without fistula, nicotine dependence, anxiety, and depressive episodes. Resident #67's admission minimum data set (MDS) with an assessment reference date (ARD) of 5/29/19 assessed the resident with a BIMS (brief interview for mental status) as 6/15. Section J Health Conditions indicated the resident, at the time of the interview, did not have pain. Resident #67's current comprehensive care plan identified the focus area for pain initiated 5/10/19 and revised on 5/23/19. Interventions: assist with positioning for comfort, non-pharmacological interventions for pain, and therapy screens as needed. Resident #67's July 2019 physician's orders read in part Oxycodone hcl (hydrogen chloride) Tablet 5 mg (milligrams) Give 1 tablet by mouth q (every) 6 hours as needed for pain. The surveyor reviewed the July 2019 electronic medication administration records (eMARs) on 7/18/19. Resident #67 was administered Oxycodone 5 mg twenty-three (23) times from 7/3/19 through 7/18/19 for pain ratings from 2 (lowest) to 9 (highest). The surveyor reviewed the progress notes for 7/3/19. The 7/3/19 progress noted timed 18:36 (6:36 p.m.) read, Oxycodone HCL Tablet 5 mg Give 1 tablet by mouth every 6 hours as needed for pain pulled from stat box. No non-pharmacological interventions documented. The progress note dated 7/6/19 at 21:49 (9:49 p.m.) read in part Oxycodone HCL Tablet 5 mg Give 1 tablet by mouth every 6 hours as needed for pain was requested by resident, resident could not express type of pain, location of pain and level of pain. No non-pharmacological interventions documented. The 7/9/19 23:05 (11:05 p.m.) progress note read, Oxycodone HCL Tablet 5 mg Give 1 tablet by mouth every 6 hours as needed for pain. No non-pharmacological interventions documented. The 7/11/19 05:32 a.m. progress note read, Oxycodone HCL Tablet 5 mg Give 1 tablet by mouth every 6 hours as needed for pain. There were not any non-pharmacological interventions documented. The 7/13/19 07:42 a.m. progress note read, Oxycodone HCL Tablet 5 mg Give 1 tablet by mouth every 6 hours as needed for pain. There were no non-pharmacological interventions documented. The 7/14/19 12:23 p.m. progress note read, Oxycodone HCL Tablet 5 mg Give 1 tablet by mouth every 6 hours as needed for pain. There were no non-pharmacological interventions documented. The 7/15/19 14:57 (2:57 p.m.) progress note read, Oxycodone HCL Tablet 5 mg Give 1 tablet by mouth every 6 hours as needed for pain. There were no non-pharmacological interventions documented. The 7/15/19 22:54 (10:54 p.m.) progress note read, Oxycodone HCL Tablet 5 mg Give 1 tablet by mouth every 6 hours as needed for pain. There were no non-pharmacological interventions documented. The 7/16/19 04:57 a.m. progress note read, Oxycodone HCL Tablet 5 mg Give 1 tablet by mouth every 6 hours as needed for pain. There were no non-pharmacological interventions documented. The 7/16/19 21:32 (9:32 p.m.) progress note read, Oxycodone HCL Tablet 5 mg Give 1 tablet by mouth every 6 hours as needed for pain. There were no non-pharmacological interventions documented. The 7/17/19 06:20 a.m. progress note read, Oxycodone HCL Tablet 5 mg Give 1 tablet by mouth every 6 hours as needed for pain. There were no non-pharmacological interventions documented. The 7/17/19 20:31 (8:31 p.m.) progress note read, Oxycodone HCL Tablet 5 mg Give 1 tablet by mouth every 6 hours as needed for pain. There were no non-pharmacological interventions documented. The surveyor informed the regional director of clinical services of the above concern with the lack of non-pharmacological interventions prior to the administration of Oxycodone twelve times during July 2019 on 7/18/19 at 10:24 a.m. Resident #67 received Oxycodone 23 times from 7/3/19 through 7/18/19. The regional director of clinical services stated he/she was unaware of the interventions on the care plan. The surveyor requested the current care plan from the regional director of clinical services and the facility policy on pain management. The care plan for pain read as follows: Resident #67's current comprehensive care plan identified the focus area for pain initiated 5/10/19 and revised on 5/23/19. Interventions: assist with positioning for comfort, non-pharmacological interventions for pain, and therapy screens as needed. There were not any non-pharmacological interventions offered or documented in the above progress notes prior to the administration of Resident #67's Oxycodone 5 mg tablet. The surveyor informed the administrator, director of nursing, the regional director of clinical services and the administrator-in-training of the above issue on 7/18/19 at 11:56 a.m. The surveyor reviewed the facility policy titled Pain Management and Pain Protocol on 7/18/19. The policy read in part Procedure 3. Non-pharmacological intervention will be attempted prior to the administration of PRN (whenever needed) pain medications. No further information was provided prior to the exit conference on 7/18/19. 2. The facility staff failed to provide non-pharmacological pain interventions prior to the use of pain medication for Resident #81. The clinical record of Resident #81 was reviewed 7/15/19 through 7/18/19. Resident #81 was admitted to the facility 6/13/17 and readmitted [DATE] with diagnoses that included but not limited to cardiac arrest, ventilator dependence, hypertension, tracheostomy, atrioventricular block, complete, atherosclerotic heart disease, gastroesophageal reflux disease (GERD) with esophagitis, chronic obstructive pulmonary disease (COPD), depressive disorder, anxiety, scoliosis, visual loss, acute and chronic respiratory failure with hypercapnia, and muscular dystrophy. Resident #81's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 6/7/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Section J Health Conditions assessed the resident to have received scheduled pain medication, received prn (as needed) pain medication, and received no non-medication interventions for pain. Resident #81's current comprehensive care plan identified the focus area that read alteration in comfort related to pain from Muscular Dystrophy. Date initiated 6/14/17 and revised on 6/18/19. Interventions: Administer pain medications as ordered, monitor for pain, assess for pain every shift, eliminate or reduce causative factors, refer to pain flow sheet as needed, staff to attempt non-pharmacological interventions. Repositioning. Resident #81's July 2019 physician's orders read in part Hydrocodone-Acetaminophen Tablet 7.5-325 mg (milligrams) Give 1 tablet by mouth every 6 hours as needed for pain. The surveyor reviewed the July 2019 electronic medication administration records. Resident #81 received pain medications thirty-one times from 7/1/19 through 7/16/19. Of the dates and times administered, fourteen (14) did not have non-medication interventions documented in the progress notes or on the electronic medication administration records (eMARs): 7/3/19 at 1320 (1:20 p.m.) 7/3/19 at 2148 (9:48 p.m.) 7/4/19 at 0600 7/6/19 at 1219 7/6/19 at 1831 (6:31 p.m.) 7/7/19 at 0840 7/8/19 at 2003 (8:03 p.m.) 7/9/19 at 0653 7/11/19 at 0639 7/12/19 at 2050 (8:50 p.m.) 7/13/19 at 0734 7/13/19 at 1900 (7:00 p.m.) 7/14/19 at 1132 7/15/19 at 1651 (4:51 p.m.) The surveyor discussed the above lack of non-medication interventions with the director of nursing on 7/18/19 at 8:21 a.m. The DON stated the staff need to offer non-pharm interventions prior to use and document those interventions. The surveyor informed the DON that the record documents mainly nurses that work in the evenings and at nights. The DON stated some of those nurses were new. The surveyor requested the facility policy on pain management. The surveyor informed the administrator, director of nursing, the regional director of clinical services and the administrator-in-training of the above issue on 7/18/19 at 11:56 a.m. The surveyor reviewed the facility policy titled Pain Management and Pain Protocol on 7/18/19. The policy read in part Procedure 3. Non-pharmacological intervention will be attempted prior to the administration of PRN (whenever needed) pain medications. No further information was provided prior to the exit conference on 7/18/19. 3. The facility staff failed to provide non-medication interventions prior to pain medication administration for Resident #260. The clinical record of Resident #260 was reviewed 7/15/19 through 7/18/19. Resident #260 was admitted to the facility 6/24/19 and readmitted [DATE] with diagnoses that included but not limited to ventilator associated pneumonia, protein-calorie malnutrition, extradural and subdural abscess, quadriplegia, chronic respiratory failure, pressure ulcer sacral region, stage 2, osteomyelitis of vertebra, lumbosacral region, Hepatitis A, Hepatitis B, Hepatitis C, opioid abuse, hypertension, cocaine abuse, stimulant abuse, tracheostomy status, gastrostomy status, and dependence on ventilator. The admission MDS (minimum data set) assessment had not yet been completed but other clinical documentation indicated the resident was not cognitively impaired, did require total assistance with all aspects of care, was a quadriplegia, and was ventilator dependent. Resident #260's current comprehensive care plan identified the focus area for pain r/t (related to) osteomyelitis initiated 6/25/19 and revised 6/25/19. Interventions included: assist with positioning for comfort, meds (medications) as ordered, and provide distractions prn (as needed) such as television, or activities. Interaction with others, reading material as able. Resident #260's July 2019 physician's orders read in part Hydrocodone-Acetaminophen (Hycet Solution) 7.5-325 mg (milligram)/15ml (milliliter) Give 15 ml by mouth every 4 hours as needed for pain-start date 7/2/19 and discontinued 7/16/19. Resident #260's July 2019 physician's orders read in part Oxycodone Hcl Tablet 5 mg (milligrams) Give 1 tablet by mouth every 4 hours as needed for pain. Resident #260 received Hycet 7.5-325mg thirty-two (32) times from 7/2/19 through 7/16/19. Fifteen (15) of those administered were administered prior to the use of a non-medication intervention. Those days and times were: 7/3/19 at 1409 (2:09 p.m.) 7/3/19 at 2045 (8:45 p.m.) 7/4/19 at 0458 7/6/19 at 1005 7/6/19 at 1545 (3:45 p.m.) 7/7/19 at 1313 (1:13 p.m.) 7/7/19 at 1758 (5:58 p.m.) 7/8/19 at 2301 (11:01 p.m.) 7/9/19 at 0714 7/10/19 at 0018 7/10/19 at 1100 7/13/19 at 0052 7/13/19 at1236 7/14/19 at 1117 7/15/19 at 1629 (4:29 p.m.) Resident #260 received Oxycodone 5 mg twenty-one (21) times from 7/10/19 through 7/17/19. Of those administered, eight (8) were administered prior to the use on a non-medication intervention. Those days and times were: 7/10/19 at 1459 (2:59 p.m.) 7/11/19 at 0548 7/12/19 at 1152 7/13/19 at 0829 7/14/19 at 1022 7/15/19 at 1303 (1:03 p.m.) 7/15/19 at 2013 (8:13 p.m.) 7/16/19 at 0109 The surveyor informed the director of nursing of the above concern on 7/18/19 at 8:30 a.m. that the staff had not offered/documented non-medication interventions prior to administration on the above days/times. The DON stated some of the residents don't want to try interventions. They know they can have the medications and they want them when they want them. The surveyor requested the facility policy on pain management on 7/18/19. The surveyor reviewed the facility policy titled Pain Management and Pain Protocol on 7/18/19. The policy read in part Procedure 3. Non-pharmacological intervention will be attempted prior to the administration of PRN (whenever needed) pain medications. No further information was provided prior to the exit conference on 7/18/19.

Based on observation, clinical record review, staff interview, and facility document review failed to determines that drug records are in order and that an account of all controlled drugs were maintained and periodically reconciled by completing the shift verification of controlled substances record on the special care unit for 15 opportunities. The findings included: During the survey from 7/15/19 through 7/18/19, the surveyor observed three medication carts on each of the three units. On 7/16/19 at 2:24 PM, the Special Care Unit medication cart was checked with licensed practical nurse #1. The surveyor and L.P.N. #1 checked the shift verification of controlled substances for June 2019 and July 2019. The surveyor identified the following areas where there was not a signature from the on-coming nurse or a signature from the off-going nurse: On 6/28/19 Day shift, there was not a signature by the off-going nurse. On 6/30/19 Day shift, there was not a signature by the off-going nurse. On 7/3/19 Day shift, there was not a signature by the on-coming nurse. On 7/3/19 Night shift, there is not a signature by the off-going nurse. On 7/6/19 Night shift, there was not a signature by the off-going nurse. On 7/7/19 Night shift, there was not a signature by the on-coming nurse. On 7/8/19 Day shift, there was not a signature by the on-coming nurse. On 7/13/19 Day shift, there was not a signature by the off-going nurse. On 7/13/19 Night shift, there was not a signature by the on-coming nurse. On 7/14/19 Night shift, there was not a signature by the off-going nurse. On 7/14/19 Day shift, there was not a signature by the on-coming nurse. On 7/15/19 Day shift-No signatures of on-going or off-going nurse. On 7/15/19 Night Shift, there was not a signature by the off-going nurse. On 7/16/19 Day shift, there was not a signature by the on-coming nurse. On 7/16/19 Night shift, there was not a signature by either the on-coming nurse or the off-going nurse. The legend at the top of the form read: 1. Two licensed nurses shall reconcile all doses of controlled substances stored in the assigned medication cart at the change of each shift. 2. The oncoming nurse shall inspect each package of controlled medication and read the remaining quantity in each package. 3. The off-going nurse shall read the remaining quantity documented on each resident Controlled Substance Declining Inventory record and record their findings. 4. Each nurse performing the reconciliation shall place his/her signature on the appropriate line for the date and shift. 5. If the quantities do not match, notify the Nursing Supervisor immediately to initiate an investigation. The surveyor interviewed licensed practical nurse #1 on 7/16/19 at 2:24 p.m. if the completion of the shift verification of controlled substances should be done each shift. L.P.N. #1 stated yes and then stated, I haven't signed off from this morning. The surveyor informed the director of nursing (DON) of the above concern on 7/18/19 at 8:55 a.m. The DON stated the controlled sheets should be completed each shift. The surveyor requested the facility policy on storage of medication. The facility policy titled 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles Revision Date 10/31/16 read in part 17. Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis. The surveyor informed the administrator, the director of nursing, the regional director of clinical services and the administrator-in-training of the above issue on 7/18/19 at 11:56 a.m. No further information was provided prior to the exit conference on 7/18/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure 1 of 34 residents was free of an unnecessary psychotropic medication (Resident #260). The findings included: The facility staff failed to identify and monitor resident specific target behaviors and identify non-pharmacological interventions associated with the use of Klonopin and Ativan for Resident #260. The clinical record of Resident #260 was reviewed 7/15/19 through 7/18/19. Resident #260 was admitted to the facility 6/24/19 and readmitted [DATE] with diagnoses that included but not limited to ventilator associated pneumonia, protein-calorie malnutrition, extradural and subdural abscess, quadriplegia, chronic respiratory failure, pressure ulcer sacral region, stage 2, osteomyelitis of vertebra, lumbosacral region, Hepatitis A, Hepatitis B, Hepatitis C, opioid abuse, hypertension, cocaine abuse, stimulant abuse, tracheostomy status, gastrostomy status, and dependence on ventilator. The admission MDS (minimum data set) assessment had not yet been completed but other clinical documentation indicated the resident was not cognitively impaired, did require total assistance with all aspects of care, was a quadriplegia, and was ventilator dependent. The current comprehensive care plan for Resident #260 had the focus area that read the resident uses anti-anxiety medications r/t (related to) anxiety disorder. Date initiated 7/9/19 and revision on 7/9/19. Interventions included to assess/record occurrence of targeted behaviors, educate the resident/family/and/or caregivers about risks, benefits and the side effects and or toxic symptoms of, and give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness. The July 2019 physician's orders were reviewed 7/15/19 through 7/18/19. Physician's orders included Ativan 0.5 mg (milligrams) every 6 hours as needed for 3 days-start date 7/3/19 and Klonopin 0.5 mg Give 0.25 mg by mouth every 12 hours as needed for anxiety for 14 days-start date 7/8/19. The surveyor was unable to locate specific behaviors for the use of Ativan and Klonopin. The surveyor was unable to locate non-pharmacological interventions prior to the use of Ativan and Klonopin. The July electronic medication administration record (eMAR) documented that Resident #260 was administered Ativan 0.5 mg on 7/3/19 at 1643 (4:43 p.m.), 7/4/19 at 1359 (1:59 p.m.), 7/5/19 at 1027 and 7/6/19 at 1005. The surveyor reviewed the facility progress notes for 7/3/19 through 7/6/19. None of the progress notes documented that Resident #260 was offered non-medication interventions prior to use. Resident #260 was administered Klonopin 0.25 mg twelve times from 7/9/19 through 7/17/19. Resident #260 was not offered non-medication interventions prior to medication administration nine times (9). 7/9/19 at 0707 Non-medication interventions were not documented in progress note prior to medication administration. 7/9/19 at 1925 (7:25 p.m.) No non-medication intervention documented in progress note prior to medication administration. 7/10/19 at 1743 (5:43 p.m.) No non-medication intervention documented in progress note prior to medication administration. 7/11/19 at 0548 No non-medication intervention documented in progress note prior to medication administration. 7/11/19 at 2308 (11:08 p.m.) No non-medication intervention documented in progress note prior to medication administration. 7/12/19 at 1107 No non-medication intervention documented in progress note prior to medication administration. 7/13/19 at 0829 No non-medication intervention documented in progress note prior to medication administration. 7/14/19 at 0751 No non-medication intervention documented in progress note prior to medication administration. 7/15/19 at 1514 (3:14 p.m.) No non-medication intervention documented in progress notes prior to medication administration. The surveyor informed the regional director of clinical services of the above concern on 7/16/19 at 6:33 p.m. and requested the behavior monitoring sheets for Ativan and Klonopin for Resident #260. The surveyor informed the director of nursing of the above concern on 7/18/19 at 8:26 a.m. The surveyor informed the director of nursing the care plan did not identify targeted behaviors or any non-medication interventions. The surveyor was unable to locate behavior monitoring sheets for Ativan and Klonopin. The DON stated the behavior monitoring had been corrected when brought to her/his attention. The surveyor requested the facility policy on psychotropic medication monitoring. The surveyor reviewed the facility policy titled Psychotropic Medication Documentation and Review Revised 2015 on 7/18/19. The policy read in part Procedure: A. Residents receiving psychotropic medication will have a Behavior/Intervention Monthly Flow Record (BFR) (Form 4.11) initiated on admission or whenever psychotropic meds are ordered. a. Each psychotropic medication will be entered on BFR. b. Resident specific behaviors related to medication use will be entered on BFR. c. Diagnosis for the reason psychotropic medication is being given will be documented in medical record. B. Nurses will document on the following every shift: b. specific non-medication interventions used-entered code as indicated on BFR. The surveyor informed the administrator, the director of nursing, the regional director of clinical services and the administrator-in-training of the above concern on 7/18/19 at 11:56 a.m. No further information was provided prior to the exit conference on 7/18/19.

Based on observations, staff interviews, clinical document review, and during a medication pass and pour observation, it was determined the facility staff failed to ensure a medication error rate of less than 5%. There were three (3) errors in thirty-one (31) opportunities resulting in a medication error rate of 9.68%. The findings include: Medication errors were observed while completing the Medication Administration Task. There were three (3) errors in thirty-one (31) opportunities resulting in a medication error rate of 9.68%. On 7/12/19 at 8:48 a.m., LPN (licensed practical nurse) #11 was observed administering medications to Resident #20. LPN #11 reported that two (2) of Resident #20's medications, which were ordered for 9:00 a.m., were not found in the medication cart. These medications were Allopurinol and Lantus Insulin. LPN #11 looked in the unit's medication storage area and reported the two (2) medications were not available to be administered to Resident #20. After the medications were discovered to not be available, LPN #11 contacted the provider and obtained orders to hold the two (2) unavailable medications. On 7/12/19 at 8:48 a.m. LPN #11 was observed to administer Sodium Polystyrene Sulfonate Suspension to Resident #20. The bottle was noted to have the instructions for how to mix the medication covered by an adhesive label therefore unable to be read. LPN #11 consulted with LPN #12 about how much of the medication (which was a powder) should be mixed with water to obtain the ordered dose. It was decided that three (3) teaspoons of the medication should be mixed with water to get the ordered dose. The three (3) teaspoons were administered to Resident #20. Resident #20's clinical documentation included the following medication order: Sodium Polystyrene Sulfonate Suspension 15GM/60ML. Give 60 ml by mouth one time a day for hyperkalemia. (Hyperkalemia is when the potassium level in one's blood is elevated.) The facility's pharmacy staff provided administration information about Sodium Polystyrene Sulfonate. This information included the following: The average total daily adult dose of sodium polystyrene sulfonate is 15 g. to 60 g. administered as a 15-g dose (four level teaspoons), one to four times daily. LPN #11 was observed to administer three (3) teaspoons not four (4) teaspoons of Sodium Polystyrene Sulfonate to Resident #20. The following information was found in a policy titled 6.0 General Dose Preparation and Medication Administration (with an effective date of 12/1/07 and the most recent revision date of 01/01/13): Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct time, for the correct resident . This policy was provided to the survey team by the Regional Director of Clinical Services (RDCS) on 7/18/19 at 12:50 p.m.; the RDCS reported this policy was obtained from the facility's pharmacy. On 7/17/19 at 10:45 a.m., the aforementioned three (3) medication errors were discussed during a survey team meeting with the facility's Director of Nursing, Administrator, Administrator-In-Training, Regional Director of Clinical Services, and Regional Vice-President of Operations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interview, and facility document review, the facility staff failed to ensure that 1 of 4 Residents observed during a medication pass and pour observation were free of significant medication errors, Resident # S1. The findings included: The facility staff failed to appropriately administer Lantus via insulin pen to Resident # S1. Resident # S1 was a [AGE] year-old- female who was originally admitted to the facility on [DATE], with a readmission date of 6/17/19. Diagnoses included but were not limited to; type 2 diabetes mellitus, obesity, hypertension, and anemia. Resident # S1 had orders that included but were not limited to, Lantus Solution 100 unit/ML (milliliter) Inject 20 unit subcutaneously two times a day for dm (diabetes mellitus). On 9/12/19 at 9:29 am, the surveyor observed LPN # 2 (licensed practical nurse) administer medications to Resident # S1. The surveyor observed LPN # 2 as she administered 20 units of Lantus via insulin pen to Resident # S1 on the left side of her abdomen. The surveyor observed LPN # 2 as she pressed the injection button on the insulin pen, and immediately removed the insulin pen from Resident # S1's left abdomen. The surveyor observed that LPN # 2 did not hold the Lantus pen in place for 10 seconds following the injection to ensure that full dose of Lantus had been delivered. On 9/12/19 at 4:09 pm, the surveyor interviewed LPN # 2. The surveyor asked LPN # 2 why she did not pinch the skin on Resident # S1's abdomen when she administered the 20 units of Lantus with the insulin pen. LPN # 2 stated, She usually pinches it herself. The surveyor informed LPN # 2 that Resident # S1 did not pinch her skin during the administration of the Lantus. The surveyor asked LPN #2 why she did not hold the insulin pen in place after pressing the injection button to ensure that Resident # S1 had received all of the medication. LPN #2 stated, I thought I did. On 9/12/19 at 4:30 pm, the director of nursing provided the surveyor with the facility standard of practice for Lantus Solostar (insulin glargine injection). The facility standard of practice contained documentation that included but was not limited to, .Step 5. Inject the dose A. Use the injection method as instructed by your health care professional. B. Insert the needle into the skin C. Deliver the dose by pressing the injection button in all the way. The number in the window will return to 0 as you inject. D. Keep the injection button pressed all the way in. Slowly count to 10 before you withdraw the needle from the skin. This ensures that the full dose will be delivered. On 9/12/19 at 4:35pm, the administrator, administrator in training, the director of nursing, and regional director of clinical services were made aware of the findings as stated above. The administrative team was provided the opportunity to ask questions and provide additional information to dispute the deficient practice as stated above. No further information regarding this issue was presented to the survey team prior to the exit conference on 9/12/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility staff failed to ensure an accurate clinical record for 1 of 34 Residents in the survey sample, Resident # 86. The findings included: The facility staff failed to ensure that complete advanced directive documentation was in the clinical record for Resident # 86. Resident # 86 was a [AGE] year-old-female that was admitted to the facility on [DATE]. Diagnoses included but were not limited to, cognitive communication deficit, hypertension, Alzheimer's disease, and Type 2 diabetes mellitus. The clinical record for Resident # 86 was reviewed on 7/16/19 at 9:44 am. The most recent MDS (minimum data set) assessment for Resident # 86 was a significant change assessment with an ARD (assessment reference date) of 6/12/19. Section C of the MDS assesses cognitive patterns. In Section C1000, the facility staff documented that Resident # 86's cognitive status was moderately impaired. The current plan of care for Resident # 86 was reviewed and revised on 3/7/19. The facility staff documented a focus area for Resident # 86 as, Resident has chosen DNR, DNI (do not recesutate, do not intubate). The facility staff documented a goal for this focus area as, Resident's code status will be honored daily through next review date. Resident # 86 had orders that included but were not limited to, Code: No code/DNR, which was initiated by the physician on 5/28/19. On 7/16/19 at 10:35 am, the surveyor observed a Durable Do Not Resuscitate Order form in the clinical record for Resident # 86. The surveyor observed a handwritten X documented next to the following statement on the form: While capable of making an informed decision, the patient has executed a written advanced directive which appoints a person Authorized to Consent on the Patient's behalf with authority to direct that life-prolonging procedures be withheld or withdrawn. (Signature of Person Authorized to Consent on the Patient's Behalf is required.). The surveyor reviewed the entire clinical record for Resident # 86 and did not locate an advanced directive document for Resident # 86. On 7/17/19 at 8:15 am, the surveyor spoke with the administrator in training and made him aware that the advanced directive documents were not located in Resident # 86's clinical record. On 7/17/19 at 2:33 pm, the administrator in training provided the surveyor with a copy of a Durable Power of Attorney for Resident # 86. The surveyor observed a fax time stamp 07/07/2019 WED (Wednesday) 13:14 (1:14 pm)at the top of the durable power of attorney form for Resident # 86 that had been provided by the administrator in training. The surveyor asked the administrator in training to explain the fax time stamp that had been observed at the top of the durable power of attorney document for Resident # 86. On 7/17/19 at 2:47 pm, the administrator in training and the facility social service director informed the surveyor that document that had originally been submitted by Resident # 86's family only had the last two pages of the durable power of attorney, and when the surveyor asked for the document, the facility staff contacted the family and requested that the family fax the document to the facility. The administrator in training agreed that the durable power of attorney documentation was not complete in the clinical record for Resident # 86 at the time the surveyor reviewed and requested documentation. On 7/17/19 at 6:42 pm, the regional vice president of operations, the regional director of clinical services, the administrator, the administrator in training, and the director of nursing were made aware of the findings as stated above. No further information regarding this issue was provided to the survey team prior to the exit conference on 7/18/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to ensure an infection control program during a medication pass and pour observation and for 4 of 34 residents (Resident 21, Resident #91, Resident #79, and Resident #20). The findings included: 1. The facility staff failed to perform hand hygiene during a medication pass and pour observation on 7/16/19 with licensed practical nurse #2. The surveyor observed a medication pass and pour observation on 7/16/19 beginning at 8:12 a.m. with licensed practical nurse #2. L.P.N. #2 used hand sanitizer before entering the medication cart to begin the medication pass. L.P.N. #2 prepared seven medications for Resident #21 and administered the medications. L.P.N. #2 returned to the medication cart. No hand washing was observed upon exiting Resident #21's room or prior to entering the medication cart. L.P.N. #2 left the medication cart, went to the medication room for two medications for Resident #21, poured the two medications, administered the two medications to Resident #21, exited the resident room, and returned to the medication cart. No hand washing or hand hygiene was observed except the initial use of hand sanitizer. L.P.N. #2 entered the medication cart and began to prepare Resident #20's medication. L.P.N. #2 prepared three medications for the resident. L.P.N. #2 locked the medication cart, entered Resident #20's room and administered the medications. While administering the medications, Resident #20 dropped one of the medications on the floor [Aspirin 81 mg (milligrams)]. L.P.N. #2 picked the dropped medication from the floor with bare hands, returned to the medication cart, placed the dropped pill in the sharps container and headed to the medication room to retrieve a new Aspirin 81 mg from the floor stock. L.P.N. #2 did not perform hand hygiene after picking the pill up from the floor, going to the medication cart to discard the dropped pill, and entering and exiting the medication room. The surveyor requested the facility policy on handwashing from the director of nursing on 7/16/19 at 4:56 p.m. The facility policy titled Hand Washing Date Revised: August 2015 read 3. Perform hand hygiene a. before and after having contact with residents. G. Wash hands with either plain or antimicrobial soap and water or rub hands with an alcohol based formulation before handling medication and preparing food. The surveyor informed the administrator, the director of nursing, the regional director of clinical services, and the administrator-in-training of the above observation on 7/18/19 at 11:56 a.m. The surveyor interviewed L.P.N. #2 on 7/18/19 12:19 p.m. L.P.N. #2 stated an in-service had been held that morning about the location of germicidal sprays and making sure medications were locked appropriately. L.P.N. #2 stated the spray wasn't available for use and L.P.N. #2 stated I got nervous. No further information was provided prior to the exit conference on 7/18/19. 2. The facility staff failed to follow physician's orders for reverse isolation for Resident #91. The clinical record of Resident #91 was reviewed 7/15/19 through 7/18/19. Resident #91 was admitted to the facility 6/13/19 with diagnoses, that included but not limited to sepsis, metastatic colon cancer, type 2 diabetes mellitus, morbid obesity, urogenital implants, chronic urinary retention, hypertension, chronic obstructive pulmonary disease, obstructive sleep apnea, systemic lupus erythematous, depression, and congestive heart failure. Resident #91's admission minimum data set (MDS) with an assessment reference date (ARD) of 6/20/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #91's current comprehensive care plan had the focus area that read Resident is at risk of infection due to recent chemotherapy treatments secondary to cancer. Date initiated 6/18/19. Interventions: Reverse isolation precautions as ordered. The July 2019 physician's orders for Resident #91 read in part Reverse Isolation. The surveyor observed Resident #91 on 7/15/19 at 3:26 p.m. The surveyor observed a treatment cart between the resident's door and the entrance to the bedroom. The treatment cart contained PPE (personal protective equipment). There was no sign on the door describing the type of isolation. Resident #91 stated to the surveyor the type of isolation he/she was currently on. I have cancer and you have to wear gloves and a mask when you come into my room. The surveyor interviewed licensed practical nurse #7 on 7/15/19 at 3:27 p.m. L.P.N. #7 stated Resident #91 was on reverse isolation and a sign should be on the door. The surveyor and L.P.N. #7 checked the door for signage for isolation. There was none. L.P.N. #7 stated she would contact the physician to see if isolation should continue. The surveyor interviewed the director of nursing on 7/15/19 at 4:14 p.m. regarding reverse isolation. The DON stated a sign should be on the door directing staff and visitors what precautions to take. The surveyor requested the facility policy on reverse isolation. The director of nursing provided the surveyor with the Reverse Isolation Precautions Guidelines for Immunocompromised Residents/Patients on 7/16/19 at 11:30 a.m. The guidelines read in part The purpose is to protect the resident/patient from any germs the staff or visitors are carrying. Residents/patients, who have a decreased immune system (neutropenic), usually from chemotherapy, may be placed in reverse isolation. For a resident/patient in reverse isolation, staff should wear gloves, a mask, and a gown. The use of Standard Precautions for all residents/patients and Transmission-Based Precautions for specified patients, as recommended in this guideline, should reduce the acquisition by these residents/patients of institutionally acquired bacteria from other patients and environments. The surveyor reviewed the facility policy titled Infection Control-Transmission Based Precautions Date Revised April 2016. The policy read in part D. A sign will be placed on the door frame of the resident's room indicating that visitors should stop at Nurses Station before entering. The surveyor informed the administrator, the director of nursing, the regional director of clinical services, the regional vice president of operations, and the administrator-in-training of the above issue on 7/17/19 at 11:35 a.m. No further information was provided prior to the exit conference on 7/18/19. 3. The facility staff failed to follow infection control guidelines for Resident #79 who was on contact isolation. The surveyor was unable to locate the site of the infection for contact precautions. The clinical record of Resident #79 was reviewed 7/15/19 through 7/18/19. Resident #79 was admitted to the facility 5/2/19 and readmitted [DATE] with diagnoses that included but not limited to pneumonia, persistent vegetative state, adult failure to thrive, severe sepsis with septic shock, neuromuscular dysfunction of the bladder, dysphagia, hypothyroidism, acute respiratory failure, dependence on respirator, tracheostomy status, unspecified coma, and non-traumatic intracerebral hemorrhage. Resident #79's 30-day minimum data set (MDS) assessment with an assessment reference date (ARD) of 7/3/19 assessed the resident to be in a persistent vegetative state in Section B0100. The surveyor observed wound care on 7/17/19 at 8:33 a.m. with licensed practical nurse #3. Resident #79's door had a sign that read Contact Precautions. L.P.N. #3 knocked and entered the room and hands washed. L.P.N. #3 returned to the treatment cart and cleaned the over-the-bed table with a Sani-cloth wipe. L.P.N. #3 left the treatment cart, went into Resident #79's room and washed hands. L.P.N. #3 returned to treatment cart and placed a barrier on the table. L.P.N. #3 removed supplies from cart-poured hydrogel into graduated cup and placed on barrier. Cleaned scissors with Sani cloth and placed on barrier. Removed Maxorb Extra AG 2 packages and placed on table. Dated all dressings prior to entering the resident's room. L.P.N. #3 placed a box of gloves, an opened package of telfa, 4x4's and a bottle of normal saline on the over-the-bed table. L.P.N. #3 donned gown, masks and gloves, entered Resident #79's room with the over-the-bed table, and positioned the table on the left side of the bed. Resident #79 was turned to the left side. Old dressing on left leg (hip region) removed and discarded. Gloves off and hands washed. Gloves applied and dressing on coccyx/sacrum removed. Gloves off and discarded. Hands washed. Gloves applied. Area on left leg cleaned with normal saline and discarded. Gloves removed and hands washed. Gloves applied. Maxorb extra AG applied. Covered with telfa (dated prior to applying). Gloves removed and hands washed. L.P.N. #3 then left the resident's room, went to treatment cart for supplies, and then returned. L.P.N. #3 did not remove gown or masks when exiting Resident #79's room and re-entering. Upon return to room, L.P.N. #3 did wash hands and gloves applied. Area on coccyx cleaned with normal saline. Gloves removed and hands washed. Gloves applied. Area cleaned again with normal saline. Gloves off and hands washed. Gloves applied. Maxorb Extra AG applied then Telfa Island dressing applied (dated prior to applying). L.P.N. #3 removed gloves and washed hands. Gloves on and cleaned scissors before leaving the room. L.P.N. #3 removed gloves and washed hands. Over-the-bed table and the box of gloves removed from the room. L.P.N. #3 cleaned the top of the over-the- bed table with Sani-wipe cloth. None of the metal frame of the over-the-bed table was cleaned with any type of disinfectant. The box of gloves was placed back on top of the treatment cart. The surveyor interviewed L.P.N. #3 about the wound care observations. The surveyor questioned L.P.N. #3 if the gown and masks should have been removed and hands washed when the nurse exited the room to get supplies from the treatment cart. L.P.N. #3 stated he/she thought he/she should but then didn't. The surveyor also asked about taking gloves and the over-the-bed-table in and out of Resident #79's room. The surveyor asked if those items should be dedicated items and left in the resident's room. L.P.N. #3 stated he/she should have used the resident's over-the-bed table and left the box of gloves in the room when wound care was finished. The surveyor interviewed the director of nursing (DON) on 7/17/19 at 10:00 a.m. and requested the facility policy on isolation, standard precautions, the July 2019 physician orders and Resident #79's current wound care orders and the site of the infection. The DON was informed of the surveyor's observations during wound care. The DON stated the gloves and table should have been left in the room and gown and masks should have been removed when L.P.N. #3 left the room. The surveyor reviewed the facility policy titled Infection Control-Transmission Based Precautions-Date Revised April 2016 on 7/17/19. The policy read in part Procedure 1. Contact Precautions-d. Resident -Care equipment-use disposable non-critical equipment (thermometers, B/P (blood pressure) cuffs, stethoscope, etc.) or implement resident-dedicated equipment. If common use of equipment is unavoidable, clean and disinfect equipment before use on another resident. The surveyor did not receive the facility policy on Standard Precautions. On 7/18/19 at 8:00 a.m., the director of nursing stated Resident #79's contact isolation had been removed. The director of nursing stated the resident had been on isolation prior to admission and the most recent progress note dated 7/16/19 did not address the reason for the isolation. The surveyor informed the administrator, the director of nursing, the regional director of clinical services, and the administrator-in-training of the above concern on 7/18/19 at 11:56 a.m. No further information was provided prior to the exit conference on 7/18/19. 4. Facility staff members failed to ensure point-of-care equipment (a glucometer) was cleaned prior to returning it to its storage area and facility staff members failed to ensure used laboratory blood draw equipment/supplies were not commingled with clean, unused laboratory blood draw equipment/supplies. On 7/16/19 at 10:45 a.m., LPN (licensed practical nurse) #14 was observed to attempt to collect Resident #20's blood; LPN #14 made two (2) unsuccessful attempts to collect Resident #20's blood. Registered Nurse (RN) #11 was assisting LPN #14 with the attempt to collect the blood. It was noted after each of the two unsuccessful attempts that the protective device was put in place over the used butterfly needle but the used butterfly needle was placed in the laboratory caddy which also held clean blood collection supplies. On 7/16/19 at 11:10 a.m., LPN #11 was observed to use a point-of-care device (a glucometer) to obtain a FSBS (finger stick blood sugar) test on Resident #20. LPN #11 was observed to return the glucometer to its storage area in the medication cart without cleaning and disinfecting the glucometer. The following information, guiding the cleaning of the facility's glucometer, was found in a facility policy titled Blood Glucose Monitoring via Finger Stick and Cleaning of Glucometers (with the most recent revised date of 11/28/2018): Wipe glucometer surface using a germicidal disposable wipe with bleach per manufacturer's directions and recommendation. The Surface must be visibly wet. a. Friction is the key to cleaning and disinfecting environmental surfaces. b. Take care not to get liquid in the test strip and key code ports of the meter. This policy indicated the aforementioned cleaning should occur prior to obtaining blood for testing and after the blood test is completed. The following information was found in the facility's glucometer's User Instruction Manual: Cleaning and Disinfecting: The cleaning procedure is needed to clean dirt as well as blood and other body fluids on the exterior of the meter and lancing device before performing the disinfection procedure. The disinfection procedure is needed to prevent transmission of blood-borne pathogens. -The meter should be cleaned and disinfected after use on each patient. This Blood Glucose Monitoring System may only be used for testing multiple patients when Standard Precautions and the manufacturer's disinfection procedures are followed . Cleaning . 1. Wear appropriate protective gears [sic] such as disposable gloves. 2. Open the cap of the disinfectant container and pull out 1 towelette and close the cap. 3. Wipe the entire surface of the meter 3 times horizontally and 3 times vertically using one towelette to clean blood and other body fluids. 4. Dispose of the used towelette in a trash bin. The meter should be cleaned prior to each disinfection step. Disinfecting . 5. Pull out 1 new towelette and wipe the entire surface of the meter 3 times horizontally and 3 times vertically using a new towelette to remove blood-borne pathogens. 6. Dispose of the used towelette in a trash bin. 7. Allow exteriors to remain wet for the corresponding contact time for each disinfectant. 8. After disinfection, the user's gloves should be removed to be thrown away and hands washed before proceeding to the next patient. The following information was found in the facility policy titled Infection Control (with an effective date of May 2015): .Staff and residents shall maintain clean work areas . All waste products shall be placed in appropriate containers . On 7/17/19 at 10:45 a.m., the following infection control concerns were discussed during a survey team meeting with the facility's Director of Nursing, Administrator, Administrator-In-Training, Regional Director of Clinical Services, and Regional Vice-President of Operations: (a) observations of used butterfly needles being placed in the laboratory caddy which contained cleaned blood draw equipment and supplies and (b) the observation of a point-of-care device (glucometer) being returned to its storage area after use without first being cleaned and disinfected.

Based on observation and staff interview the facility staff failed to prepare, distribute and serve food in a manner that would prevent foodborne illnesses. The facility staff did not complete any hand hygiene prior to obtaining food temperatures. The findings included: The facility staff when obtaining food temperatures allowed the top of the thermometer to touch the food. The top of this thermometer is what the facility staff held while obtaining food temperatures. The facility staff did not have gloves in place, were not observed to wash their hands prior to obtaining the temperatures, and were observed touching the top of the thermometer with their bare hands. On 07/16/19 at 11:41 a.m., the surveyor entered the kitchen to obtain tray line temperatures. Tray aide #1 was working in the kitchen area and stated she would obtain the tray line temperatures. Tray aide #1 did not wash their hands or apply any gloves prior to obtaining these temperatures. Tray aide #1 picked up the thermometer with their bare hands and placed the thermometer into a pan of broccoli. Tray aide #1 did not hold onto the thermometer and allowed the top of the thermometer to lay backwards onto the broccoli which resulted in the top of the thermometer touching the broccoli. On 07/16/19 at 12:00 p.m., the administrator in training who was in the kitchen stated he would discard the broccoli. The administrator, administrator in training, director of nursing, regional director of clinical services, and the regional vice president of operations were notified of the above issue during a meeting with the survey team on 07/17/19 at 11:35 a.m. No further information regarding these issues were provided to the survey team prior to the exit conference.